P U L M O N A RY R E H A B I L I TAT I O N
Balance Training in Pulmonary Rehabilitation EFFECTS ON PSYCHOSOCIAL OUTCOMES
Wajdi Mkacher, PhD; Marwa Mekki, MS; Faten Chaieb, MD; Zouhair Tabka, MD, PhD; Yassine Trabelsi, PhD
■ PURPOSE: Balance impairment in chronic obstructive pulmonary disease (COPD) is associated with a worsening of quality of life (QOL) as related with fatigue perception, depression, and anxiety. The aim of this study was to examine the effect of balance training included in pulmonary rehabilitation (PR) on QOL, fatigue perception, depression, and anxiety in patients with COPD. ■ METHODS: Patients were assigned randomly to an intervention or PR-only group. The intervention group underwent balance training 3 times a week for 6 months concurrently with PR. The PR-only group received 6 months of the standard PR program. Quality of life was assessed at the beginning and at the end of the program using the St. George’s Respiratory Questionnaire, fatigue using the Multidimensional Fatigue Inventory, and anxiety and depression using the Hospital Anxiety and Depression Scale. Exercise tolerance was determined from the 6-minute walk test. ■ RESULTS: After the 6 months of the intervention or PR-only, both the intervention (n = 32) and PR-only (n = 30) groups improved their QOL (activity, impact, and total) with a significant intergroup difference (P < .05) after PR. General fatigue, physical fatigue, and reduced activity decreased in both groups with an intergroup difference (P < .05). Anxiety decreased significantly in both groups with a greater change in the intervention group (P < .01). Only the intervention group had an improved depression score at the end of 6 months. ■ CONCLUSIONS: Balance training added to PR improved health-related QOL, fatigue, and mental health in patients with COPD.
K E Y
W O R D S
anxiety balance training COPD depression fatigue quality of life Author Affiliation: Department of Physiology and Function Testing, Faculty of Medicine, University of Sousse, Sousse, Tunisia. Supported by the Faculty of Medicine, University of Sousse, Sousse, Tunisia. The authors declare no conflicts of interest. Correspondence: Wajdi Mkacher, PhD, Department of Physiology, Sousse Faculty of Medicine, Ave Mohamed Karoui, 4002, Sousse, Tunisia (wajdi_mkacher@ yahoo.fr). DOI: 10.1097/HCR.0000000000000122
Chronic obstructive pulmonary disease (COPD) is one of the major causes of mortality and morbidity throughout the world. Many people suffer from this disease for years and die prematurely because of it. Chronic obstructive pulmonary disease is the fourth leading cause of death in the world, and further increases in prevalence and mortality are predicted in the coming decades.1 The World Bank and the World Health Organization have projected that COPD will be the third leading cause of death in 2020 and the fifth
highest cause of disability in the world. Approximately 2.5 million people die each year worldwide because of COPD.2 The goal for managing patients with COPD is not only to reduce symptoms, prevent exacerbations, decrease mortality, prevent complications, and delay disease progression but also to improve overall health and psychosocial status while preserving, for as long as possible, the patient’s psychomotor function and professional activities.1 Quality of life (QOL),
278 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 278
18/06/15 1:26 PM
recognized as a secondary alteration of this disease,3 has therefore become an important element in the overall assessment of patients with COPD, in addition to the traditional biomedical parameters.4 As the prevalence and the age of adults living with COPD increase, the need to maintain function and QOL becomes ever more important. Several studies have suggested that the prevalence of anxiety and depression among patients with COPD is substantially greater than lifetime rates in the general population and higher than in patients with other pulmonary diseases such as bronchial asthma and tuberculosis,5 or other chronic diseases such as chronic heart failure.6 A strong association between the presence of depressive symptoms and the increase in exacerbation rates has been identified.7,8 In this way, perceived anxiety and depression can have even more negative consequences in patients with COPD. Recent studies have shown a reduction in perceived anxiety and depression among patients with COPD who are enrolled in pulmonary rehabilitation (PR) programs,9-11 but some believe that further studies are needed.12 Patients with COPD often experience a variety of symptoms, with fatigue and dyspnea being the 2 most common symptoms. Even though fatigue is reported to occur with nearly the same frequency as dyspnea, there are only a few studies focusing on fatigue in this group of patients.13-15 Fatigue is one of the most distressing symptoms for patients with this illness,16,17 and it significantly impairs both functional performance and quality of living.18,19 Recent studies have shown strong relationships between these symptoms and the impairment of postural balance and subsequently fall risk in patients with COPD.20,21 In this population, postural control has been improved as a result of balance training.22 To our knowledge, this is the first study to assess the effects of balance training on patients with COPD enrolled in a PR program on fatigue perception, QOL, anxiety, and depression. Therefore, the aim of the study was to examine the effects of 6 months of balance training included as part of a PR program on fatigue, perception, QOL, anxiety, and depression in patients with COPD.
METHODS
ria and postbronchodilator results of spirometry of forced expiratory volume in 1 second to forced vital capacity ratio (FEV1/FVC) less than 0.7; (2) severe classification of COPD (FEV1 values between 30% and 50% predicted); (3) absence of other obstructive pulmonary diseases (eg, asthma and bronchiectasis); and (4) no musculoskeletal or neurologic conditions that might affect their ability to exercise, symptomatic cardiac disease, or previous lung surgery. Individuals who smoked and those who demonstrated a significant response to bronchodilators, defined as an increase in FEV1 greater than 12% from predicted values, were excluded from our study. Patients were assigned randomly to a PR-only or intervention group using a computer-generated randomization list. Before the study, the subjects had been fully informed of the aim of the research, the protocol and the procedures of the investigation before signing a written consent form, which was in accordance with legal requirements and the Declaration of Helsinki and was approved by the Farhat Hached Hospital Research Ethics Committee.
Study Design Patients were evaluated over 2 days at baseline and at the end of the 6-month training program. On the first day of the study, subjects were informed about the purpose of the study, completed pulmonary function testing using a body plethysmograph, and responded to questionnaires about fatigue, QOL, anxiety, and depression. On the second day, patients were assessed using a standard 6-minute walk test (6MWT).
Outcome Measures Fatigue perception Fatigue was assessed using the Multidimensional Fatigue Inventory (MFI-20), a 20-item self-report instrument designed to measure subjective fatigue. The questionnaire asks patients to describe how they have been feeling within the past 2 weeks. The tool consists of 5 dimensions covering general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue. Each dimension has 4 items, and each item is scored from 1 to 5, with higher scores representing greater levels of fatigue.23
Health-related quality of life
Patients for this 6-month study were recruited at the Farhat Hached Hospital. Inclusion criteria were as follows: (1) diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease1 crite-
To investigate the QOL of our patients, the French version of the St. George’s Respiratory Questionnaire (SGRQ) was used. The questions were asked by a trained physician, to avoid nonresponses or multiple responses. The questionnaire consists of 3 component scores (symptoms, activity, and impacts) plus a total
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 279
Study Participants
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 279
18/06/15 1:26 PM
score with scores ranging from 0 to 100 points. Higher scores represent poor quality of health in any of the domains.24
Depression and anxiety Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS).25,26 The HADS has been specifically developed for detection of anxiety and depression in patients with somatic conditions. It is a validated screening tool for symptom severity in cases of anxiety and depression in patients with chronic diseases (including COPD).26,27 It is divided into an anxiety subscale (HADS-A) and a depression subscale (HADS-D) both containing 7 items, rated 0 to 3, giving a possible maximum score for anxiety and depression of 21. Scores less than 8 indicate no clinical distress; scores from 8 to 10 indicate possible psychiatric morbidity; and scores 11 or more indicate probable pathologic levels of distress.25
Physical Measures Pulmonary function test All subjects underwent a pulmonary function test with determination of FEV1 and FVC. Measurement was performed using a constant volume plethysmograph (ZAN 500 Body II, Meßgreräte ZAN GmbH, Germany) according to the European Respiratory Society recommendations.28
6MWT The 6MWT was performed before and after the rehabilitation program. It was conducted in accordance with international recommendations.29 Subjects were instructed to walk at their own maximal pace along a hospital corridor that is 40 m long as far as possible in 6 minutes. No encouragement was given, and subjects were informed each minute of the time remaining. The subjects were allowed to stop, but they could start again, if possible. Chairs were placed along the corridor. Dyspnea was measured using the Borg scale before the start and at the end of the 6MWT.30 Heart rate and oxygen saturation (SpO2) were recorded continuously throughout the 6MWT by portable Spiropalm (Cosmed, Rome, Italy). At the end of the 6MWT, the total distance walked was recorded.29
Intervention Patients assigned to the intervention group underwent balance training 3 times a week for 24 weeks (72 sessions). Training sessions lasted 30 minutes and were monitored by health professionals. Participants received individualized exercises and attention regarding the level of difficulty and approach to train-
ing progression. The content of the balance training program was developed according to previous works,31,22 guidelines for fall prevention,32 and consultation with physicians and gerontology specialists. Balance training consisted of 4 main types of exercise: (1) stance exercises, (2) transition exercises, (3) gait exercises, and (4) functional strengthening as explained in Table 1. When a participant was able to complete a task independently and with little instability, the difficulty level was increased progressively by introducing more challenging conditions (eg, eyes closed, addition of a secondary cognitive task, increased speed/repetition, or perturbations). Before beginning the study, the training program was pilot tested using 2 patients with COPD to determine any equipment needed for safety and the feasibility of the balance program within the constraints of a 30-minute session. Balance training occurred concurrently with inpatient PR, which included (1) supervised exercise training twice per day, 3 times a week, (2) daily breathing exercises, and (3) self-management education and psychological and social support. Three times a week, patients in the intervention group received the balance training program in place of their usual morning or afternoon exercise session. Therefore, the total time spent exercising was matched between groups. Patients assigned to the PR-only group received only the usual PR program.
Statistical Analysis All data were tested for normality with the KolmogorovSmirnov test. The data from the study are presented as means and standard deviations for all measurements. Differences at baseline and after 6 months of rehabilitation between the 2 groups were analyzed with a 2-tailed unpaired t test. Within-group differences were analyzed with a 2-tailed paired t test. The statistical program Statistica (Statistica Kernel Version 10; Stat Soft, France) was used for the analysis. The level of significance was set as P < .05.
RESULTS Sixty-two male patients (intervention group, n = 32; PR-only group, n = 30) completed the study and were included in the analysis. Baseline characteristics are provided in Table 2. There were no significant between-group differences at baseline. Questionnaire scores are summarized in Table 3. Patients in both groups showed significant improvement in the activity, impact, and total subscales of the SGRQ. Improvements in the scores in the intervention group were greater than those in patients in the
280 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 280
18/06/15 1:26 PM
T a b l e 1 • Balance Training Program Stance Exercises (Static and Dynamic ) 1. Narrow stance
Transition Exercises
Gait Exercises
Functional Strength Exercises
1. Sit to stand
1. Walking in parallel bars
1. Lower leg
Stand without support
Chair with arms (5 reps)
Tandem walk with light finger support
Toe raises (arm support): 2 × 10 reps
Eyes closed (time 20 s)
Fast-speed chair with arms (time 30 s)
Tandem walk without U/E support
Toe raises (no arm support): 2 × 10 reps
Throw and catch ball
Chair with no arms (5 reps)
Sideways walk
Heel raises (arm support): 2 × 10 reps
Count backwards
Fast-speed chair with no arms (time 30 s)
Backward walk
Heel raises (no arm support): 2 × 10 reps
Perturbations
Low seat
Tandem walk while spelling words
Walk on toes
Sit to stand and pick up objects from floor
Walk backward while naming words starting with “M”
Walk on heels
2. Tandem stance Tandem stance (time 30 s)
Sit to stand and stop
Throw and catch ball
Sit to stand and walk with head turns
Low-level obstacle
Minisquats: 2 × 10 reps
Spell backwards
Sit to stand carrying basketball
High-level obstacle
Squats (arm support): 2 × 10 reps
Eyes closed (time 20 s)
2. Sit on floor and stand up
2. Walking in open space
Squats (no arm support): 2 × 10 reps
Perturbations
With chair for descent and ascent
Kick a ball
Step-ups (arm support): 2 × 10 reps
No chair for either descent or ascent
Fast walking (>6 ms)
Step-ups (no arm support): 2 × 10 reps
One-leg stand (time 30 s)
No chair
Change in speed
Lateral step-ups (no arm support): 2 × 10 reps
Spell names with foot
Timed (safely and quickly)
Quick direction change
Lateral step-ups (arm support): 2 × 10 reps
3. One-legged stance
2. Upper leg
Throw and catch ball
Walk and count backward
Leg out to the side
Walk and recite months of the year
Eyes closed
Walk over obstacles
Abbreviations: reps, repetitions; U/E, upper extremities.
control group. No significant change in the symptoms subscale score was observed for either group. For the MFI-20, the scores for general fatigue, physical fatigue, and reduced activity were significantly decreased in both groups (P < .05) after 6 months of training. Reduced motivation and mental fatigue scores were not significantly changed in either group. The analysis of HADS data showed an improvement in the scores for anxiety in both groups, with a significant intergroup difference after 6 months in favor of the intervention group (P < .01). The depression scores were also significantly decreased in the intervention group.
6MWT parameters are presented in Table 4. Both the intervention and control groups experienced clinically important improvement33 in the 6MWT distance (52 and 50 m, respectively), dyspnea ratings, and peak heart rate after PR (P < .05), with no significant difference between groups.
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 281
DISCUSSION The aim of our study was to examine the effect of 6 months of balance training included in PR on fatigue, perception, QOL, anxiety, and depression in patients
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 281
18/06/15 1:26 PM
T a b l e 2 • Subject Characteristics at Baseline PR-Only Group (n = 30) Mean ± SD
Intervention Group (n = 32) Mean ± SD
63.5 ± 2.6
61 ± 4.1
BMI, kg/m
26.7 ± 1.8
25 ± 2.6
FEV1, % predicted
39.3 ± 8.1
40.2 ± 9.1
FEV1/FVC, % predicted
46.3 ± 10.6
47 ± 5.3
4.5 ± 1.5
4.1 ± 1.6
Age, y 2
MRC dyspnea scale, grade
Abbreviations: BMI, body mass index; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; MRC, Medical Research Council; PR, pulmonary rehabilitation; SD, standard deviation.
group (17.8% vs 9.4%; 40.2% vs22.3% and 28.9% vs 14.8%, respectively). These results are in agreement with previous findings on the effects of PR in patients with COPD, which found improved SGRQ scores after PR.34,35 The intergroup difference after the period of rehabilitation can be explained by the fact that patients with COPD have a high incidence rate of falls that are associated with a decline in QOL.20 The risk of fall decreased after balance training in a recent study,22 and this may partially explain the associated
with COPD. This study showed that fatigue, anxiety, depression, and QOL were significantly modified after 6 months of balance training as part of a rehabilitation program. On the basis of our results, it would seem that the additional stimulus provided by balance training was sufficient to promote additional gains in QOL. Our results showed a significant intergroup difference in the scores of subscales for activity and impact and total scores in favor of the experimental group compared to the PR-only group after the PR. The percentage changes were higher in the experimental
T a b l e 3 • Outcome Measures for Both Groups Before and After PR PR-Only Group (n = 30)
Intervention Group (n = 32)
Before PR Mean ± SD
After PR Mean ± SD
Before PR Mean ± SD
After PR Mean ± SD
Symptoms
51.3 ± 12.4
47.2 ± 10.1
53.1 ± 9.2
48.3 ± 7.7
Activity
71.4 ± 8.2
64.7 ± 9.1a
69.9 ± 4.1
57.4 ± 7.3b,c
Impact
38.4 ± 6.1
a
29.8 ± 8.8
37.8 ± 4.9
22.6 ± 5.2b,c
Total
51.3 ± 11.4
43.7 ± 9.7b
50.8 ± 8.7
36.1 ± 10.3b,c
General fatigue
12 ± 3
11 ± 5a
12 ± 4
9 ± 2a,c
Physical fatigue
14 ± 5
12 ± 4a
15 ± 4
11 ± 5b,c
Reduced activity
13 ± 4
12 ± 3a
13 ± 5
10 ± 2a,c
Reduced motivation
9±4
9±2
8±3
8±4
Mental fatigue
9±3
9±4
8±4
8±1
HADS (A)
12 ± 2
10 ± 3a
12 ± 4
7 ± 4a,d
HADS (D)
8±3
8±4
9±6
7 ± 3a
SGRQ
MFI-20
HADS
Abbreviations: A, anxiety; D, depression; HADS, Hospital Anxiety and Depression Scale; MFI-20, Multidimensional Fatigue Inventory; PR, pulmonary rehabilitation; SD, standard deviation; SGRQ, St. George’s Respiratory Questionnaire. P < .05, bP < .01: within-group differences before and after PR.
a
P < .05, dP < .01: between-group differences after PR.
c
282 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 282
18/06/15 1:26 PM
T a b l e 4 • 6MWT Data for Both Groups Before and After PR Control Group (N = 30)
Intervention Group (N = 32)
Before PR Mean ± SD
After PR Mean ± SD
Before PR Mean ± SD
After PR Mean ± SD
455.2 ± 34
505.6 ± 31a
459.2 ± 19.4
511.2 ± 19.3a
64 ± 3
70 ± 6a
65.8 ± 4
72.6 ± 3a
Rest
95.2 ± 3.1
96.1 ± 2,5
96.1 ± 2.1
96.8 ± 1,9
Peak
90.8 ± 2.1
91.3 ± 2
91.5 ± 1.8
91.7 ± 2.2
Rest
2. 2 ± 0.6
1.4 ± 0.3a
2.3 ± 0.4
1.5 ± 0.6a
Peak
3.9 ± 1.1
2.56 ± 1a
4.2 ± 0.9
2.7 ± 1.6a
Rest
78 ± 4
79 ± 6
81 ± 5
79 ± 5
Peak
127 ± 13
118 ± 19a
128 ± 10
117 ± 12a
6MWD, m 6MWD, % predicted SpO2, %
Dyspnea, Borg scale
HR, bpm
Abbreviations: bpm, beats per minute; 6MWD, 6-minute walk distance; HR, heart rate; PR, pulmonary rehabilitation; SD, standard deviation; SpO2, peripheral oxygen saturation. P < .05, within-group differences before and after PR.
a
improvement in QOL in patients in the experimental group. Furthermore, this improvement in the QOL might be due to the psychological benefits of exercise, which included increased motivation, desensitization to dyspnea, and decreased fear of exercise.36 By comparison, our findings are different from those of Janaudis-Ferreira and colleagues,37 who found no improvement in QOL after either 6 weeks of PR alone or PR combined with a specialized arm resistance training program. It is possible that the 6-week training period was insufficient to achieve the stimulus needed for a significant effect on QOL. Regarding fatigue perception results, there were significant improvements in the reduced activity, general and physical fatigue components of the MFI-20, but not in reduced motivation or mental fatigue in both groups. This study is the first to report changes in individual dimensions of fatigue after balance training among patients with COPD. Changes in scores for general fatigue, physical fatigue, and reduced activity after training were greater in the intervention group than in the control group. A study by Ozalevli et al21 demonstrated that fatigue is related with balance impairment and falls in patients with COPD, and the author suggests that assessment of and training to improve balance impairment among the elderly with COPD should be a component of PR programs in clinical practice. Their results showed a beneficial effect on postural control,22 and this could explain the greater reduction in fatigue scores for patients in the balance training group.
In our study, perceived anxiety decreased in both groups with a significant intergroup difference after the intervention program (P < .01) whereas depression improved only in the intervention group. A previous study showed, using multivariate regression models and controlling for age, FEV1, and depression and anxiety treatment, found that improvement in depressive symptoms was associated with improvement in fatigue and emotion.38 In addition, the decrease in depression in the balance training group could be associated with the improvement in QOL and dyspnea because these variables have been shown to have a high correlation in patients suffering from COPD.35,39 Our results are in agreement with a previous study that showed the beneficial effect of rehabilitation on perceived anxiety and depression.35 In our study, both groups received the same therapeutic education and psychological and social support to isolate the specific effect of the 2 interventions (balance training vs traditional PR). The results of our study supported the concept that balance training was associated with improvements in exercise tolerance as determined by an increase in the 6MWT distance. This decreased sensation of dyspnea can be explained by improved physical function and by other beneficial adaptations to exercise training,40 as well as some physiological changes, such as cardiac adaptations, decrease in lactic acid production, and reduction in the metabolic cost of exercise.41
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 283
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 283
18/06/15 1:26 PM
CONCLUSIONS Our findings support the benefits of combining balance training with traditional PR to achieve a greater improvement in QOL, fatigue perception, anxiety, and depression. Future studies with a larger sample and a longer intervention are necessary to further validate these findings and to standardize balance training as an integral part of PR for patients with COPD.
References 1. Global Strategy for the Diagnosis, Management and Prevention of COPD. Global initiative for chronic obstructive lung disease (GOLD). http://www.goldcopd.org/uploads/users/files/GOLD_ Report_2015.pdf. Published 2015. Accessed January 10, 2014. 2. Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ ERS position paper. Eur Respir J. 2004;23:932-946. 3. Medinas Amorós M, Mas-Tous C, Renom-Sotorra F, RubíPonseti M, Centeno-Flores MJ, Gorriz-Dolz MT. Health related quality of life is associated with COPD severity: a comparison between the GOLD staging and the BODE index. Chron Respir Dis. 2009;6:75-80. 4. Ba˛k-Drabik K, Ziora D. The impact of socioeconomic status on the quality of life in patients with chronic obstructive pulmonary disease. Pneumonol Alergol Pol. 2010;78(1):3-13. 5. Moussas G, Tselebis A, Karkanias A, et al. A comparative study of anxiety and depression in patients with bronchial asthma, chronic obstructive pulmonary disease and tuberculosis in a general hospital of chest diseases. Ann Gen Psychiatry. 2008;8:7. 6. Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. Int J Geriatr Psychiatry. 2010;8:1209-1221. 7. Janssen DJ, Spruit MA, Leue C, et al. Symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation. Chron Respir Dis. 2010;7:147-157. 8. Coventry PA, Gemmell I, Todd CJ. Psychosocial risk factors for hospital readmission in COPD patients on early discharge services: a cohort study. BMC Pulm Med. 2011;11:49. 9. Emery CF, Schein RL, Hauck ER, MacIntyre NR. Psychosocial and cognitive outcomes of a randomized trial of exercise among patients with chronic obstructive pulmonary disease. Health Psychol. 1998;8:232-240. 10. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;8:362-368. 11. Guell R, Resqueti V, Sangenis M, et al. Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD. Chest. 2006;8:899-904. 12. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;8(5 suppl):4S-42S. 13. Theander K, Cliffordson C, Torstensson O, Jakobsson P, Unosson M. Fatigue impact scale: its validation in patients with chronic obstructive pulmonary disease. Psychol Health Med. 2007;12:470-484. 14. Kapella MC, Larson JL, Patel MK, Covey MK, Berry JK. Subjective fatigue, influencing variables, and consequences in chronic obstructive pulmonary disease. Nurs Res. 2006;55:10-17.
15. Thomas LA. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Appl Nurs Res. 2009;22:79-85. 16. Graydon JE, Ross E. Influence of symptoms, lung function, mood, and social support on level of functioning of patients with COPD. Res Nurs Health. 1995;18:525-533. 17. Gift AG, Shepard CE. Fatigue and other symptoms in patients with chronic obstructive pulmonary disease: do women and men differ? J Obstet Gynecol Neonatal Nurs. 1999;28:201-208. 18. Reishtein JL. Relationship between symptoms and functional performance in COPD. Res Nurs Health. 2005;28:39-47. 19. Oga T, Nishimura K, Tsukino M, et al. Longitudinal changes in health status using the chronic respiratory disease questionnaire and pulmonary function in patients with stable chronic obstructive pulmonary disease. Qual Life Res. 2004;13:1109-1116. 20. Roig M, Eng JJ, MacIntyre DL, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respir Med. 2011;105:461-469. 21. Ozalevli S, Ilgin D, Narin S, Akkoclu A. Association between disease-related factors and balance and falls among the elderly with COPD: a cross-sectional study. Aging Clin Exp Res. 2011;23:372-377. 22. Beauchamp MK, Janaudis-Ferreira T, Parreira V, et al. A randomized controlled trial of balance training during pulmonary rehabilitation for individuals with COPD. Chest. 2013;144:18031810. 23. Smets EM, Garssen B, Bonke B, De Haes JC. The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315-325. 24. Bouchet CH, Guillemin F, Hoang Thi TH, Cornette A, Briançon S. Validation du questionnaire St-Georges pour mesurer la qualité de vie chez les insuffisants respiratoires chroniques. Rev Mal Resp. 1996;13:43-46. 25. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res. 2002;52:69-77. 26. Jones PW, Quirk FH, Baveystock CM., et al. A self-complete measure of health status for chronic airflow limitation: the St. George’s Respiratory Questionnaire. Am Rev Respir Dis. 1992;145:1321-1327. 27. Xu W, Collet JP, Shapiro S., et al. Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. Am J Respir Crit Care Med. 2008;178:913-920. 28. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report working party standardization of lung function tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Rev Mal Respir. 1994;11(suppl 3):5-40. 29. American Thoracic Society. ATS statement: guidelines for the sixminute walk test. Am J Respir Crit Care Med. 2002;166:111-117. 30. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377-381. 31. Beauchamp MK, Sibley KM, Lakhani B, et al. Impairments in systems underlying control of balance in COPD. Chest. 2012;141:1496-1503. 32. Panel on Prevention of Falls in Older Persons. American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc. 2011;59:148-157. 33. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med. 1997;155:1278-1282.
284 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 284
18/06/15 1:26 PM
34. Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65:423-428. 35. Ninot G. Anxiety and depression in COPD: a review. Rev Mal Respir. 2011;28:739-748. 36. American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation: joint ACCP/AACVPR Evidence-Based Guideline. Chest. 1997;112:1363-1396. 37. Janaudis-Ferreira T, Hill K, Goldstein RS, et al. Resistance arm training in patients with COPD: a randomized controlled trial. Chest. 2011;139:151-158. 38. Pirraglia PA, Casserly B, Velasco R, Borgia ML, Nici L. Association of change in depression and anxiety symptoms
with functional outcomes in pulmonary rehabilitation patients. J Psychosom Res. 2011;71:45-49. 39. Borge CR, Wahl AK, Moum T. Association of breathlessness with multiple symptoms in chronic obstructive pulmonary disease. J Adv Nurs. 2010;66:2688-2700. 40. Vallet G, Ahmaïdi S, Serres I, et al. Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols. Eur Respir J. 1997; 10:114-122. 41. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF, Wasserman K. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis. 1991;143: 9-18.
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 285
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 285
18/06/15 1:26 PM
Balance Training in Pulmonary Rehabilitation EFFECTS ON PSYCHOSOCIAL OUTCOMES
Wajdi Mkacher, PhD; Marwa Mekki, MS; Faten Chaieb, MD; Zouhair Tabka, MD, PhD; Yassine Trabelsi, PhD
■ PURPOSE: Balance impairment in chronic obstructive pulmonary disease (COPD) is associated with a worsening of quality of life (QOL) as related with fatigue perception, depression, and anxiety. The aim of this study was to examine the effect of balance training included in pulmonary rehabilitation (PR) on QOL, fatigue perception, depression, and anxiety in patients with COPD. ■ METHODS: Patients were assigned randomly to an intervention or PR-only group. The intervention group underwent balance training 3 times a week for 6 months concurrently with PR. The PR-only group received 6 months of the standard PR program. Quality of life was assessed at the beginning and at the end of the program using the St. George’s Respiratory Questionnaire, fatigue using the Multidimensional Fatigue Inventory, and anxiety and depression using the Hospital Anxiety and Depression Scale. Exercise tolerance was determined from the 6-minute walk test. ■ RESULTS: After the 6 months of the intervention or PR-only, both the intervention (n = 32) and PR-only (n = 30) groups improved their QOL (activity, impact, and total) with a significant intergroup difference (P < .05) after PR. General fatigue, physical fatigue, and reduced activity decreased in both groups with an intergroup difference (P < .05). Anxiety decreased significantly in both groups with a greater change in the intervention group (P < .01). Only the intervention group had an improved depression score at the end of 6 months. ■ CONCLUSIONS: Balance training added to PR improved health-related QOL, fatigue, and mental health in patients with COPD.
K E Y
W O R D S
anxiety balance training COPD depression fatigue quality of life Author Affiliation: Department of Physiology and Function Testing, Faculty of Medicine, University of Sousse, Sousse, Tunisia. Supported by the Faculty of Medicine, University of Sousse, Sousse, Tunisia. The authors declare no conflicts of interest. Correspondence: Wajdi Mkacher, PhD, Department of Physiology, Sousse Faculty of Medicine, Ave Mohamed Karoui, 4002, Sousse, Tunisia (wajdi_mkacher@ yahoo.fr). DOI: 10.1097/HCR.0000000000000122
Chronic obstructive pulmonary disease (COPD) is one of the major causes of mortality and morbidity throughout the world. Many people suffer from this disease for years and die prematurely because of it. Chronic obstructive pulmonary disease is the fourth leading cause of death in the world, and further increases in prevalence and mortality are predicted in the coming decades.1 The World Bank and the World Health Organization have projected that COPD will be the third leading cause of death in 2020 and the fifth
highest cause of disability in the world. Approximately 2.5 million people die each year worldwide because of COPD.2 The goal for managing patients with COPD is not only to reduce symptoms, prevent exacerbations, decrease mortality, prevent complications, and delay disease progression but also to improve overall health and psychosocial status while preserving, for as long as possible, the patient’s psychomotor function and professional activities.1 Quality of life (QOL),
278 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 278
18/06/15 1:26 PM
recognized as a secondary alteration of this disease,3 has therefore become an important element in the overall assessment of patients with COPD, in addition to the traditional biomedical parameters.4 As the prevalence and the age of adults living with COPD increase, the need to maintain function and QOL becomes ever more important. Several studies have suggested that the prevalence of anxiety and depression among patients with COPD is substantially greater than lifetime rates in the general population and higher than in patients with other pulmonary diseases such as bronchial asthma and tuberculosis,5 or other chronic diseases such as chronic heart failure.6 A strong association between the presence of depressive symptoms and the increase in exacerbation rates has been identified.7,8 In this way, perceived anxiety and depression can have even more negative consequences in patients with COPD. Recent studies have shown a reduction in perceived anxiety and depression among patients with COPD who are enrolled in pulmonary rehabilitation (PR) programs,9-11 but some believe that further studies are needed.12 Patients with COPD often experience a variety of symptoms, with fatigue and dyspnea being the 2 most common symptoms. Even though fatigue is reported to occur with nearly the same frequency as dyspnea, there are only a few studies focusing on fatigue in this group of patients.13-15 Fatigue is one of the most distressing symptoms for patients with this illness,16,17 and it significantly impairs both functional performance and quality of living.18,19 Recent studies have shown strong relationships between these symptoms and the impairment of postural balance and subsequently fall risk in patients with COPD.20,21 In this population, postural control has been improved as a result of balance training.22 To our knowledge, this is the first study to assess the effects of balance training on patients with COPD enrolled in a PR program on fatigue perception, QOL, anxiety, and depression. Therefore, the aim of the study was to examine the effects of 6 months of balance training included as part of a PR program on fatigue, perception, QOL, anxiety, and depression in patients with COPD.
METHODS
ria and postbronchodilator results of spirometry of forced expiratory volume in 1 second to forced vital capacity ratio (FEV1/FVC) less than 0.7; (2) severe classification of COPD (FEV1 values between 30% and 50% predicted); (3) absence of other obstructive pulmonary diseases (eg, asthma and bronchiectasis); and (4) no musculoskeletal or neurologic conditions that might affect their ability to exercise, symptomatic cardiac disease, or previous lung surgery. Individuals who smoked and those who demonstrated a significant response to bronchodilators, defined as an increase in FEV1 greater than 12% from predicted values, were excluded from our study. Patients were assigned randomly to a PR-only or intervention group using a computer-generated randomization list. Before the study, the subjects had been fully informed of the aim of the research, the protocol and the procedures of the investigation before signing a written consent form, which was in accordance with legal requirements and the Declaration of Helsinki and was approved by the Farhat Hached Hospital Research Ethics Committee.
Study Design Patients were evaluated over 2 days at baseline and at the end of the 6-month training program. On the first day of the study, subjects were informed about the purpose of the study, completed pulmonary function testing using a body plethysmograph, and responded to questionnaires about fatigue, QOL, anxiety, and depression. On the second day, patients were assessed using a standard 6-minute walk test (6MWT).
Outcome Measures Fatigue perception Fatigue was assessed using the Multidimensional Fatigue Inventory (MFI-20), a 20-item self-report instrument designed to measure subjective fatigue. The questionnaire asks patients to describe how they have been feeling within the past 2 weeks. The tool consists of 5 dimensions covering general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue. Each dimension has 4 items, and each item is scored from 1 to 5, with higher scores representing greater levels of fatigue.23
Health-related quality of life
Patients for this 6-month study were recruited at the Farhat Hached Hospital. Inclusion criteria were as follows: (1) diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease1 crite-
To investigate the QOL of our patients, the French version of the St. George’s Respiratory Questionnaire (SGRQ) was used. The questions were asked by a trained physician, to avoid nonresponses or multiple responses. The questionnaire consists of 3 component scores (symptoms, activity, and impacts) plus a total
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 279
Study Participants
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 279
18/06/15 1:26 PM
score with scores ranging from 0 to 100 points. Higher scores represent poor quality of health in any of the domains.24
Depression and anxiety Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS).25,26 The HADS has been specifically developed for detection of anxiety and depression in patients with somatic conditions. It is a validated screening tool for symptom severity in cases of anxiety and depression in patients with chronic diseases (including COPD).26,27 It is divided into an anxiety subscale (HADS-A) and a depression subscale (HADS-D) both containing 7 items, rated 0 to 3, giving a possible maximum score for anxiety and depression of 21. Scores less than 8 indicate no clinical distress; scores from 8 to 10 indicate possible psychiatric morbidity; and scores 11 or more indicate probable pathologic levels of distress.25
Physical Measures Pulmonary function test All subjects underwent a pulmonary function test with determination of FEV1 and FVC. Measurement was performed using a constant volume plethysmograph (ZAN 500 Body II, Meßgreräte ZAN GmbH, Germany) according to the European Respiratory Society recommendations.28
6MWT The 6MWT was performed before and after the rehabilitation program. It was conducted in accordance with international recommendations.29 Subjects were instructed to walk at their own maximal pace along a hospital corridor that is 40 m long as far as possible in 6 minutes. No encouragement was given, and subjects were informed each minute of the time remaining. The subjects were allowed to stop, but they could start again, if possible. Chairs were placed along the corridor. Dyspnea was measured using the Borg scale before the start and at the end of the 6MWT.30 Heart rate and oxygen saturation (SpO2) were recorded continuously throughout the 6MWT by portable Spiropalm (Cosmed, Rome, Italy). At the end of the 6MWT, the total distance walked was recorded.29
Intervention Patients assigned to the intervention group underwent balance training 3 times a week for 24 weeks (72 sessions). Training sessions lasted 30 minutes and were monitored by health professionals. Participants received individualized exercises and attention regarding the level of difficulty and approach to train-
ing progression. The content of the balance training program was developed according to previous works,31,22 guidelines for fall prevention,32 and consultation with physicians and gerontology specialists. Balance training consisted of 4 main types of exercise: (1) stance exercises, (2) transition exercises, (3) gait exercises, and (4) functional strengthening as explained in Table 1. When a participant was able to complete a task independently and with little instability, the difficulty level was increased progressively by introducing more challenging conditions (eg, eyes closed, addition of a secondary cognitive task, increased speed/repetition, or perturbations). Before beginning the study, the training program was pilot tested using 2 patients with COPD to determine any equipment needed for safety and the feasibility of the balance program within the constraints of a 30-minute session. Balance training occurred concurrently with inpatient PR, which included (1) supervised exercise training twice per day, 3 times a week, (2) daily breathing exercises, and (3) self-management education and psychological and social support. Three times a week, patients in the intervention group received the balance training program in place of their usual morning or afternoon exercise session. Therefore, the total time spent exercising was matched between groups. Patients assigned to the PR-only group received only the usual PR program.
Statistical Analysis All data were tested for normality with the KolmogorovSmirnov test. The data from the study are presented as means and standard deviations for all measurements. Differences at baseline and after 6 months of rehabilitation between the 2 groups were analyzed with a 2-tailed unpaired t test. Within-group differences were analyzed with a 2-tailed paired t test. The statistical program Statistica (Statistica Kernel Version 10; Stat Soft, France) was used for the analysis. The level of significance was set as P < .05.
RESULTS Sixty-two male patients (intervention group, n = 32; PR-only group, n = 30) completed the study and were included in the analysis. Baseline characteristics are provided in Table 2. There were no significant between-group differences at baseline. Questionnaire scores are summarized in Table 3. Patients in both groups showed significant improvement in the activity, impact, and total subscales of the SGRQ. Improvements in the scores in the intervention group were greater than those in patients in the
280 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 280
18/06/15 1:26 PM
T a b l e 1 • Balance Training Program Stance Exercises (Static and Dynamic ) 1. Narrow stance
Transition Exercises
Gait Exercises
Functional Strength Exercises
1. Sit to stand
1. Walking in parallel bars
1. Lower leg
Stand without support
Chair with arms (5 reps)
Tandem walk with light finger support
Toe raises (arm support): 2 × 10 reps
Eyes closed (time 20 s)
Fast-speed chair with arms (time 30 s)
Tandem walk without U/E support
Toe raises (no arm support): 2 × 10 reps
Throw and catch ball
Chair with no arms (5 reps)
Sideways walk
Heel raises (arm support): 2 × 10 reps
Count backwards
Fast-speed chair with no arms (time 30 s)
Backward walk
Heel raises (no arm support): 2 × 10 reps
Perturbations
Low seat
Tandem walk while spelling words
Walk on toes
Sit to stand and pick up objects from floor
Walk backward while naming words starting with “M”
Walk on heels
2. Tandem stance Tandem stance (time 30 s)
Sit to stand and stop
Throw and catch ball
Sit to stand and walk with head turns
Low-level obstacle
Minisquats: 2 × 10 reps
Spell backwards
Sit to stand carrying basketball
High-level obstacle
Squats (arm support): 2 × 10 reps
Eyes closed (time 20 s)
2. Sit on floor and stand up
2. Walking in open space
Squats (no arm support): 2 × 10 reps
Perturbations
With chair for descent and ascent
Kick a ball
Step-ups (arm support): 2 × 10 reps
No chair for either descent or ascent
Fast walking (>6 ms)
Step-ups (no arm support): 2 × 10 reps
One-leg stand (time 30 s)
No chair
Change in speed
Lateral step-ups (no arm support): 2 × 10 reps
Spell names with foot
Timed (safely and quickly)
Quick direction change
Lateral step-ups (arm support): 2 × 10 reps
3. One-legged stance
2. Upper leg
Throw and catch ball
Walk and count backward
Leg out to the side
Walk and recite months of the year
Eyes closed
Walk over obstacles
Abbreviations: reps, repetitions; U/E, upper extremities.
control group. No significant change in the symptoms subscale score was observed for either group. For the MFI-20, the scores for general fatigue, physical fatigue, and reduced activity were significantly decreased in both groups (P < .05) after 6 months of training. Reduced motivation and mental fatigue scores were not significantly changed in either group. The analysis of HADS data showed an improvement in the scores for anxiety in both groups, with a significant intergroup difference after 6 months in favor of the intervention group (P < .01). The depression scores were also significantly decreased in the intervention group.
6MWT parameters are presented in Table 4. Both the intervention and control groups experienced clinically important improvement33 in the 6MWT distance (52 and 50 m, respectively), dyspnea ratings, and peak heart rate after PR (P < .05), with no significant difference between groups.
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 281
DISCUSSION The aim of our study was to examine the effect of 6 months of balance training included in PR on fatigue, perception, QOL, anxiety, and depression in patients
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 281
18/06/15 1:26 PM
T a b l e 2 • Subject Characteristics at Baseline PR-Only Group (n = 30) Mean ± SD
Intervention Group (n = 32) Mean ± SD
63.5 ± 2.6
61 ± 4.1
BMI, kg/m
26.7 ± 1.8
25 ± 2.6
FEV1, % predicted
39.3 ± 8.1
40.2 ± 9.1
FEV1/FVC, % predicted
46.3 ± 10.6
47 ± 5.3
4.5 ± 1.5
4.1 ± 1.6
Age, y 2
MRC dyspnea scale, grade
Abbreviations: BMI, body mass index; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; MRC, Medical Research Council; PR, pulmonary rehabilitation; SD, standard deviation.
group (17.8% vs 9.4%; 40.2% vs22.3% and 28.9% vs 14.8%, respectively). These results are in agreement with previous findings on the effects of PR in patients with COPD, which found improved SGRQ scores after PR.34,35 The intergroup difference after the period of rehabilitation can be explained by the fact that patients with COPD have a high incidence rate of falls that are associated with a decline in QOL.20 The risk of fall decreased after balance training in a recent study,22 and this may partially explain the associated
with COPD. This study showed that fatigue, anxiety, depression, and QOL were significantly modified after 6 months of balance training as part of a rehabilitation program. On the basis of our results, it would seem that the additional stimulus provided by balance training was sufficient to promote additional gains in QOL. Our results showed a significant intergroup difference in the scores of subscales for activity and impact and total scores in favor of the experimental group compared to the PR-only group after the PR. The percentage changes were higher in the experimental
T a b l e 3 • Outcome Measures for Both Groups Before and After PR PR-Only Group (n = 30)
Intervention Group (n = 32)
Before PR Mean ± SD
After PR Mean ± SD
Before PR Mean ± SD
After PR Mean ± SD
Symptoms
51.3 ± 12.4
47.2 ± 10.1
53.1 ± 9.2
48.3 ± 7.7
Activity
71.4 ± 8.2
64.7 ± 9.1a
69.9 ± 4.1
57.4 ± 7.3b,c
Impact
38.4 ± 6.1
a
29.8 ± 8.8
37.8 ± 4.9
22.6 ± 5.2b,c
Total
51.3 ± 11.4
43.7 ± 9.7b
50.8 ± 8.7
36.1 ± 10.3b,c
General fatigue
12 ± 3
11 ± 5a
12 ± 4
9 ± 2a,c
Physical fatigue
14 ± 5
12 ± 4a
15 ± 4
11 ± 5b,c
Reduced activity
13 ± 4
12 ± 3a
13 ± 5
10 ± 2a,c
Reduced motivation
9±4
9±2
8±3
8±4
Mental fatigue
9±3
9±4
8±4
8±1
HADS (A)
12 ± 2
10 ± 3a
12 ± 4
7 ± 4a,d
HADS (D)
8±3
8±4
9±6
7 ± 3a
SGRQ
MFI-20
HADS
Abbreviations: A, anxiety; D, depression; HADS, Hospital Anxiety and Depression Scale; MFI-20, Multidimensional Fatigue Inventory; PR, pulmonary rehabilitation; SD, standard deviation; SGRQ, St. George’s Respiratory Questionnaire. P < .05, bP < .01: within-group differences before and after PR.
a
P < .05, dP < .01: between-group differences after PR.
c
282 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 282
18/06/15 1:26 PM
T a b l e 4 • 6MWT Data for Both Groups Before and After PR Control Group (N = 30)
Intervention Group (N = 32)
Before PR Mean ± SD
After PR Mean ± SD
Before PR Mean ± SD
After PR Mean ± SD
455.2 ± 34
505.6 ± 31a
459.2 ± 19.4
511.2 ± 19.3a
64 ± 3
70 ± 6a
65.8 ± 4
72.6 ± 3a
Rest
95.2 ± 3.1
96.1 ± 2,5
96.1 ± 2.1
96.8 ± 1,9
Peak
90.8 ± 2.1
91.3 ± 2
91.5 ± 1.8
91.7 ± 2.2
Rest
2. 2 ± 0.6
1.4 ± 0.3a
2.3 ± 0.4
1.5 ± 0.6a
Peak
3.9 ± 1.1
2.56 ± 1a
4.2 ± 0.9
2.7 ± 1.6a
Rest
78 ± 4
79 ± 6
81 ± 5
79 ± 5
Peak
127 ± 13
118 ± 19a
128 ± 10
117 ± 12a
6MWD, m 6MWD, % predicted SpO2, %
Dyspnea, Borg scale
HR, bpm
Abbreviations: bpm, beats per minute; 6MWD, 6-minute walk distance; HR, heart rate; PR, pulmonary rehabilitation; SD, standard deviation; SpO2, peripheral oxygen saturation. P < .05, within-group differences before and after PR.
a
improvement in QOL in patients in the experimental group. Furthermore, this improvement in the QOL might be due to the psychological benefits of exercise, which included increased motivation, desensitization to dyspnea, and decreased fear of exercise.36 By comparison, our findings are different from those of Janaudis-Ferreira and colleagues,37 who found no improvement in QOL after either 6 weeks of PR alone or PR combined with a specialized arm resistance training program. It is possible that the 6-week training period was insufficient to achieve the stimulus needed for a significant effect on QOL. Regarding fatigue perception results, there were significant improvements in the reduced activity, general and physical fatigue components of the MFI-20, but not in reduced motivation or mental fatigue in both groups. This study is the first to report changes in individual dimensions of fatigue after balance training among patients with COPD. Changes in scores for general fatigue, physical fatigue, and reduced activity after training were greater in the intervention group than in the control group. A study by Ozalevli et al21 demonstrated that fatigue is related with balance impairment and falls in patients with COPD, and the author suggests that assessment of and training to improve balance impairment among the elderly with COPD should be a component of PR programs in clinical practice. Their results showed a beneficial effect on postural control,22 and this could explain the greater reduction in fatigue scores for patients in the balance training group.
In our study, perceived anxiety decreased in both groups with a significant intergroup difference after the intervention program (P < .01) whereas depression improved only in the intervention group. A previous study showed, using multivariate regression models and controlling for age, FEV1, and depression and anxiety treatment, found that improvement in depressive symptoms was associated with improvement in fatigue and emotion.38 In addition, the decrease in depression in the balance training group could be associated with the improvement in QOL and dyspnea because these variables have been shown to have a high correlation in patients suffering from COPD.35,39 Our results are in agreement with a previous study that showed the beneficial effect of rehabilitation on perceived anxiety and depression.35 In our study, both groups received the same therapeutic education and psychological and social support to isolate the specific effect of the 2 interventions (balance training vs traditional PR). The results of our study supported the concept that balance training was associated with improvements in exercise tolerance as determined by an increase in the 6MWT distance. This decreased sensation of dyspnea can be explained by improved physical function and by other beneficial adaptations to exercise training,40 as well as some physiological changes, such as cardiac adaptations, decrease in lactic acid production, and reduction in the metabolic cost of exercise.41
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 283
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 283
18/06/15 1:26 PM
CONCLUSIONS Our findings support the benefits of combining balance training with traditional PR to achieve a greater improvement in QOL, fatigue perception, anxiety, and depression. Future studies with a larger sample and a longer intervention are necessary to further validate these findings and to standardize balance training as an integral part of PR for patients with COPD.
References 1. Global Strategy for the Diagnosis, Management and Prevention of COPD. Global initiative for chronic obstructive lung disease (GOLD). http://www.goldcopd.org/uploads/users/files/GOLD_ Report_2015.pdf. Published 2015. Accessed January 10, 2014. 2. Celli BR, MacNee W, Agusti A, et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ ERS position paper. Eur Respir J. 2004;23:932-946. 3. Medinas Amorós M, Mas-Tous C, Renom-Sotorra F, RubíPonseti M, Centeno-Flores MJ, Gorriz-Dolz MT. Health related quality of life is associated with COPD severity: a comparison between the GOLD staging and the BODE index. Chron Respir Dis. 2009;6:75-80. 4. Ba˛k-Drabik K, Ziora D. The impact of socioeconomic status on the quality of life in patients with chronic obstructive pulmonary disease. Pneumonol Alergol Pol. 2010;78(1):3-13. 5. Moussas G, Tselebis A, Karkanias A, et al. A comparative study of anxiety and depression in patients with bronchial asthma, chronic obstructive pulmonary disease and tuberculosis in a general hospital of chest diseases. Ann Gen Psychiatry. 2008;8:7. 6. Yohannes AM, Willgoss TG, Baldwin RC, Connolly MJ. Depression and anxiety in chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. Int J Geriatr Psychiatry. 2010;8:1209-1221. 7. Janssen DJ, Spruit MA, Leue C, et al. Symptoms of anxiety and depression in COPD patients entering pulmonary rehabilitation. Chron Respir Dis. 2010;7:147-157. 8. Coventry PA, Gemmell I, Todd CJ. Psychosocial risk factors for hospital readmission in COPD patients on early discharge services: a cohort study. BMC Pulm Med. 2011;11:49. 9. Emery CF, Schein RL, Hauck ER, MacIntyre NR. Psychosocial and cognitive outcomes of a randomized trial of exercise among patients with chronic obstructive pulmonary disease. Health Psychol. 1998;8:232-240. 10. Griffiths TL, Burr ML, Campbell IA, et al. Results at 1 year of outpatient multidisciplinary pulmonary rehabilitation: a randomised controlled trial. Lancet. 2000;8:362-368. 11. Guell R, Resqueti V, Sangenis M, et al. Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD. Chest. 2006;8:899-904. 12. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based clinical practice guidelines. Chest. 2007;8(5 suppl):4S-42S. 13. Theander K, Cliffordson C, Torstensson O, Jakobsson P, Unosson M. Fatigue impact scale: its validation in patients with chronic obstructive pulmonary disease. Psychol Health Med. 2007;12:470-484. 14. Kapella MC, Larson JL, Patel MK, Covey MK, Berry JK. Subjective fatigue, influencing variables, and consequences in chronic obstructive pulmonary disease. Nurs Res. 2006;55:10-17.
15. Thomas LA. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Appl Nurs Res. 2009;22:79-85. 16. Graydon JE, Ross E. Influence of symptoms, lung function, mood, and social support on level of functioning of patients with COPD. Res Nurs Health. 1995;18:525-533. 17. Gift AG, Shepard CE. Fatigue and other symptoms in patients with chronic obstructive pulmonary disease: do women and men differ? J Obstet Gynecol Neonatal Nurs. 1999;28:201-208. 18. Reishtein JL. Relationship between symptoms and functional performance in COPD. Res Nurs Health. 2005;28:39-47. 19. Oga T, Nishimura K, Tsukino M, et al. Longitudinal changes in health status using the chronic respiratory disease questionnaire and pulmonary function in patients with stable chronic obstructive pulmonary disease. Qual Life Res. 2004;13:1109-1116. 20. Roig M, Eng JJ, MacIntyre DL, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respir Med. 2011;105:461-469. 21. Ozalevli S, Ilgin D, Narin S, Akkoclu A. Association between disease-related factors and balance and falls among the elderly with COPD: a cross-sectional study. Aging Clin Exp Res. 2011;23:372-377. 22. Beauchamp MK, Janaudis-Ferreira T, Parreira V, et al. A randomized controlled trial of balance training during pulmonary rehabilitation for individuals with COPD. Chest. 2013;144:18031810. 23. Smets EM, Garssen B, Bonke B, De Haes JC. The multidimensional fatigue inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res. 1995;39:315-325. 24. Bouchet CH, Guillemin F, Hoang Thi TH, Cornette A, Briançon S. Validation du questionnaire St-Georges pour mesurer la qualité de vie chez les insuffisants respiratoires chroniques. Rev Mal Resp. 1996;13:43-46. 25. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale: an updated literature review. J Psychosom Res. 2002;52:69-77. 26. Jones PW, Quirk FH, Baveystock CM., et al. A self-complete measure of health status for chronic airflow limitation: the St. George’s Respiratory Questionnaire. Am Rev Respir Dis. 1992;145:1321-1327. 27. Xu W, Collet JP, Shapiro S., et al. Independent effect of depression and anxiety on chronic obstructive pulmonary disease exacerbations and hospitalizations. Am J Respir Crit Care Med. 2008;178:913-920. 28. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report working party standardization of lung function tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Rev Mal Respir. 1994;11(suppl 3):5-40. 29. American Thoracic Society. ATS statement: guidelines for the sixminute walk test. Am J Respir Crit Care Med. 2002;166:111-117. 30. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377-381. 31. Beauchamp MK, Sibley KM, Lakhani B, et al. Impairments in systems underlying control of balance in COPD. Chest. 2012;141:1496-1503. 32. Panel on Prevention of Falls in Older Persons. American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons. J Am Geriatr Soc. 2011;59:148-157. 33. Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH. Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients. Am J Respir Crit Care Med. 1997;155:1278-1282.
284 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:278-285
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 284
18/06/15 1:26 PM
34. Seymour JM, Moore L, Jolley CJ, et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax. 2010;65:423-428. 35. Ninot G. Anxiety and depression in COPD: a review. Rev Mal Respir. 2011;28:739-748. 36. American College of Chest Physicians, American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation: joint ACCP/AACVPR Evidence-Based Guideline. Chest. 1997;112:1363-1396. 37. Janaudis-Ferreira T, Hill K, Goldstein RS, et al. Resistance arm training in patients with COPD: a randomized controlled trial. Chest. 2011;139:151-158. 38. Pirraglia PA, Casserly B, Velasco R, Borgia ML, Nici L. Association of change in depression and anxiety symptoms
with functional outcomes in pulmonary rehabilitation patients. J Psychosom Res. 2011;71:45-49. 39. Borge CR, Wahl AK, Moum T. Association of breathlessness with multiple symptoms in chronic obstructive pulmonary disease. J Adv Nurs. 2010;66:2688-2700. 40. Vallet G, Ahmaïdi S, Serres I, et al. Comparison of two training programmes in chronic airway limitation patients: standardized versus individualized protocols. Eur Respir J. 1997; 10:114-122. 41. Casaburi R, Patessio A, Ioli F, Zanaboni S, Donner CF, Wasserman K. Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease. Am Rev Respir Dis. 1991;143: 9-18.
www.jcrpjournal.com
Balance Training and Psychosocial Outcomes in COPD / 285
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00113_LR 285
18/06/15 1:26 PM
