P U L M O N A RY R E H A B I L I TAT I O N
Effect of 6 Months of Balance Training During Pulmonary Rehabilitation in Patients With COPD Wajdi Mkacher, PhD; Marwa Mekki, MS; Zouhair Tabka, MD, PhD; Yassine Trabelsi, PhD
■ PURPOSE: Balance impairment is recognized as an important issue for patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to examine the effect of balance training as part of pulmonary rehabilitation (PR) on balance in COPD patients. ■ METHODS: Patients were randomly assigned to an intervention or usual care group. The intervention group underwent balance training 3 times a week for 6 months in addition to the standard PR. The control group received 6 months of the standard PR program only. Balance was assessed by the Timed Up and Go (TUG), Tinetti, Berg Balance Scale (BBS), and the Unipodal Stance (UST) tests. Balance confidence was rated using the ABC scale. Exercise tolerance was determined using a 6-Minute Walk Test. ■ RESULTS: Following the completion of PR, the intervention group showed improvement in all balance measures. Only TUG, ABC, and UST scores were improved in the usual care group (P < .05). Results demonstrated significant between-group differences in TUG, Tinetti, BBS, and ABC scores (P < .01) and UST score (P < .05). ■ CONCLUSIONS: Balance training incorporated into a standard PR program significantly improves scores on balance tests in COPD patients.
Chronic obstructive pulmonary disease (COPD) is one of the most important causes of death worldwide and is projected to rank third by 2020 in global burden of disease.1 The systemic nature of this disease is increasingly recognized by the scientific community.2 Impairments in peripheral muscle function, mobility, and exercise capacity are well established in these patients.3,4 Thus, different systems are affected during the course of COPD: muscle changes; metabolic, nutritional, cardiovascular, and neurological abnormalities; and osteoporosis.4 A growing body of evidence suggests that older adults with COPD show important reductions in balance control compared with age-matched usual care subjects and this may be associated with an increased fall risk in this population.5 Although information regarding postural control in www.jcrpjournal.com
K E Y
W O R D S
balance training chronic obstructive pulmonary disease pulmonary rehabilitation Author Affiliation: Department of Physiology and Lung Function Testing (UR12 ES06), Sousse 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.0000000000000109
persons with lung disease is limited, evidence suggests that balance deficits present an important secondary impairment in COPD patients.2,5-7 According to Beauchamp et al,8 the elements involved in balance (receptors, integrators, and effectors) are less effective in patients with COPD. The American Geriatrics Society recommends exercise with balance training as an essential component of a multifactorial falls intervention strategy for communitydwelling older adults who are at risk for falling.9 Although the exercise component of pulmonary rehabilitation (PR) is considered the cornerstone of rehabilitation for patients with COPD, it is focused predominately on aerobic training. Up to now, few studies have tried to combine balance training with the exercise training program Balance Training in Patients With COPD / 207
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00084_LR 207
10/04/15 7:48 PM
traditionally used in PR. A recent study supported the feasibility and effectiveness of balance training as part of PR for improving balance in patients with moderate to severe COPD.10 This small-scale trial reported poor improvement in balance after 6 weeks of training. Current guidelines for fall prevention recommend ongoing balance training beyond 6 months to achieve the most favorable results for reducing falls in older adults. Our hypothesis is that balance training has beneficial effects on postural balance in COPD patients and this reduces the risk of falling. Therefore, the aim of the study was to examine the effects of 6 months of balance training that was included as a part of PR on postural control, balance confidence, and exercise tolerance in COPD patients.
METHODS Subjects Sixty-eight COPD male subjects agreed to participate in the study. Subjects were selected according to the inclusion criteria defined as follows: (1) COPD diagnosed by pulmonary function testing; (2) clinically stable; (3) absence of other obstructive disease (eg, asthma, bronchiectasis); (4) lack of recent cardiac or neuromuscular pathologies; and (5) a fall in the last 5 years or a recent near-fall. Individuals who smoked and those who had a significant response to bronchodilators, defined as an increase >12% in forced expiratory volume in 1 second (FEV1), or if they presented with a cognitive deficiency, a neurological or locomotive condition that may impair their mobility and balance were excluded from the study. Patients were assigned randomly to an intervention or usual care group using a computer-generated randomization list. All patients continued their regular treatment with inhaled bronchodilators but could not have used inhaled glucocorticoids for at least the previous 3 years and during the training period. The study was approved by the Research Ethics Committee of Farhat Hached Hospital. In accordance with legal requirements and the Declaration of Helsinki, subjects provided written informed consent prior to participation in the study.
Study Design Subjects were evaluated at baseline and after 6 months of the training program. On the first day of the study, subjects completed pulmonary function testing and a balance assessment. On the next day, patients were assessed using a 6-Minute Walk Test (6MWT). Patients who were randomly assigned to the intervention group underwent balance training 3 times per
week for 24 weeks (72 sessions). Training sessions lasted 30 minutes and were monitored by health care professionals. Participants received individualized exercise recommendations with attention to the level of difficulty and training progression. Content of the balance training program was developed on the basis of the previous studies,8,10 guidelines for fall prevention,9 and consultation with experts. Balance training consisted of 4 main types of exercise: (1) stance exercises; (2) transition exercises; (3) gait exercises; and (4) functional strengthening. When a participant was able to independently complete a task 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, we pilot tested the training program on 2 patients with COPD to determine equipment safety and feasibility of the balance program with respect to a 30-minute session. Balance training was scheduled concurrently with outpatient PR, which included (1) supervised exercise training twice daily, 3 times per week; (2) daily breathing exercises; and (3) self-management education and psychological and social support (for both groups). 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 equal between the groups. Patients assigned to the usual care group received only the standard outpatient PR program for 6 months.
Outcome Measures Balance Assessment Timed Up and Go (TUG) Test. The TUG test was used to provide a timed measure of balance and functional mobility in our patients.11 The test requires the patient to rise from a standard armchair, walk 3 m at a comfortable pace, walk back to the chair, and sit down. A practice trial was performed (not recorded) and individuals were permitted to use a gait aid, if required. Normative data are available for elderly individuals who reside in the community.12 The TUG has high intratester and intertester reliability and predictive validity for falls in community-living adults.11,13 A test duration of 16 seconds or greater has been shown to predict falls in community-dwelling elderly persons.14
Berg Balance Scale (BBS). Functional balance was measured using the 14-item BBS.15 Activities such as transfers, reaching, turning around, and single-leg stance were graded on a scale ranging from 0 (unable/
208 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:207-213
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00084_LR 208
10/04/15 7:48 PM
unsafe) to 4 (independent/efficient/safe), with higher total scores indicating greater balance control. The BBS score has demonstrated internal consistency, intrarater and interrater reliability, content validity, construct validity, and predictive validity for determining fall risk in older adults.13 A cutoff score of 46 and less identifies those at risk of falling16,17 and age- and gender-specific scores are available in healthy populations.12
Unipedal Stance Test. Each patient’s ability to stand on one leg was assessed using the Unipedal Stance Test (UST). Patients selected the leg on which they preferred to stand for the test. They were instructed to keep their legs from touching and to maintain a unipedal stance for as long as possible. Failure to do so was defined as shifting the stance foot or placing the lifted foot on the floor. The UST was stopped and considered normal if a patient achieved 45 seconds using a unipedal stance.18 Although some investigators have used 30 seconds as a standard,19 Briggs and associates20 believed that a 45-second time limit would reduce any ceiling effect and provide a more normal distribution of times. Subjects were given 3 trials, unless they achieved 45 seconds on the first or second trial, and the greatest amount of time was recorded.
Tinetti test. The Tinetti test is a reliable clinical test for measuring balance and gait in older individuals. It has 16 items divided into 2 sections: balance (9 items) and gait (7 items), for a total score of 28. Individuals scoring
Effect of 6 Months of Balance Training During Pulmonary Rehabilitation in Patients With COPD Wajdi Mkacher, PhD; Marwa Mekki, MS; Zouhair Tabka, MD, PhD; Yassine Trabelsi, PhD
■ PURPOSE: Balance impairment is recognized as an important issue for patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to examine the effect of balance training as part of pulmonary rehabilitation (PR) on balance in COPD patients. ■ METHODS: Patients were randomly assigned to an intervention or usual care group. The intervention group underwent balance training 3 times a week for 6 months in addition to the standard PR. The control group received 6 months of the standard PR program only. Balance was assessed by the Timed Up and Go (TUG), Tinetti, Berg Balance Scale (BBS), and the Unipodal Stance (UST) tests. Balance confidence was rated using the ABC scale. Exercise tolerance was determined using a 6-Minute Walk Test. ■ RESULTS: Following the completion of PR, the intervention group showed improvement in all balance measures. Only TUG, ABC, and UST scores were improved in the usual care group (P < .05). Results demonstrated significant between-group differences in TUG, Tinetti, BBS, and ABC scores (P < .01) and UST score (P < .05). ■ CONCLUSIONS: Balance training incorporated into a standard PR program significantly improves scores on balance tests in COPD patients.
Chronic obstructive pulmonary disease (COPD) is one of the most important causes of death worldwide and is projected to rank third by 2020 in global burden of disease.1 The systemic nature of this disease is increasingly recognized by the scientific community.2 Impairments in peripheral muscle function, mobility, and exercise capacity are well established in these patients.3,4 Thus, different systems are affected during the course of COPD: muscle changes; metabolic, nutritional, cardiovascular, and neurological abnormalities; and osteoporosis.4 A growing body of evidence suggests that older adults with COPD show important reductions in balance control compared with age-matched usual care subjects and this may be associated with an increased fall risk in this population.5 Although information regarding postural control in www.jcrpjournal.com
K E Y
W O R D S
balance training chronic obstructive pulmonary disease pulmonary rehabilitation Author Affiliation: Department of Physiology and Lung Function Testing (UR12 ES06), Sousse 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.0000000000000109
persons with lung disease is limited, evidence suggests that balance deficits present an important secondary impairment in COPD patients.2,5-7 According to Beauchamp et al,8 the elements involved in balance (receptors, integrators, and effectors) are less effective in patients with COPD. The American Geriatrics Society recommends exercise with balance training as an essential component of a multifactorial falls intervention strategy for communitydwelling older adults who are at risk for falling.9 Although the exercise component of pulmonary rehabilitation (PR) is considered the cornerstone of rehabilitation for patients with COPD, it is focused predominately on aerobic training. Up to now, few studies have tried to combine balance training with the exercise training program Balance Training in Patients With COPD / 207
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00084_LR 207
10/04/15 7:48 PM
traditionally used in PR. A recent study supported the feasibility and effectiveness of balance training as part of PR for improving balance in patients with moderate to severe COPD.10 This small-scale trial reported poor improvement in balance after 6 weeks of training. Current guidelines for fall prevention recommend ongoing balance training beyond 6 months to achieve the most favorable results for reducing falls in older adults. Our hypothesis is that balance training has beneficial effects on postural balance in COPD patients and this reduces the risk of falling. Therefore, the aim of the study was to examine the effects of 6 months of balance training that was included as a part of PR on postural control, balance confidence, and exercise tolerance in COPD patients.
METHODS Subjects Sixty-eight COPD male subjects agreed to participate in the study. Subjects were selected according to the inclusion criteria defined as follows: (1) COPD diagnosed by pulmonary function testing; (2) clinically stable; (3) absence of other obstructive disease (eg, asthma, bronchiectasis); (4) lack of recent cardiac or neuromuscular pathologies; and (5) a fall in the last 5 years or a recent near-fall. Individuals who smoked and those who had a significant response to bronchodilators, defined as an increase >12% in forced expiratory volume in 1 second (FEV1), or if they presented with a cognitive deficiency, a neurological or locomotive condition that may impair their mobility and balance were excluded from the study. Patients were assigned randomly to an intervention or usual care group using a computer-generated randomization list. All patients continued their regular treatment with inhaled bronchodilators but could not have used inhaled glucocorticoids for at least the previous 3 years and during the training period. The study was approved by the Research Ethics Committee of Farhat Hached Hospital. In accordance with legal requirements and the Declaration of Helsinki, subjects provided written informed consent prior to participation in the study.
Study Design Subjects were evaluated at baseline and after 6 months of the training program. On the first day of the study, subjects completed pulmonary function testing and a balance assessment. On the next day, patients were assessed using a 6-Minute Walk Test (6MWT). Patients who were randomly assigned to the intervention group underwent balance training 3 times per
week for 24 weeks (72 sessions). Training sessions lasted 30 minutes and were monitored by health care professionals. Participants received individualized exercise recommendations with attention to the level of difficulty and training progression. Content of the balance training program was developed on the basis of the previous studies,8,10 guidelines for fall prevention,9 and consultation with experts. Balance training consisted of 4 main types of exercise: (1) stance exercises; (2) transition exercises; (3) gait exercises; and (4) functional strengthening. When a participant was able to independently complete a task 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, we pilot tested the training program on 2 patients with COPD to determine equipment safety and feasibility of the balance program with respect to a 30-minute session. Balance training was scheduled concurrently with outpatient PR, which included (1) supervised exercise training twice daily, 3 times per week; (2) daily breathing exercises; and (3) self-management education and psychological and social support (for both groups). 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 equal between the groups. Patients assigned to the usual care group received only the standard outpatient PR program for 6 months.
Outcome Measures Balance Assessment Timed Up and Go (TUG) Test. The TUG test was used to provide a timed measure of balance and functional mobility in our patients.11 The test requires the patient to rise from a standard armchair, walk 3 m at a comfortable pace, walk back to the chair, and sit down. A practice trial was performed (not recorded) and individuals were permitted to use a gait aid, if required. Normative data are available for elderly individuals who reside in the community.12 The TUG has high intratester and intertester reliability and predictive validity for falls in community-living adults.11,13 A test duration of 16 seconds or greater has been shown to predict falls in community-dwelling elderly persons.14
Berg Balance Scale (BBS). Functional balance was measured using the 14-item BBS.15 Activities such as transfers, reaching, turning around, and single-leg stance were graded on a scale ranging from 0 (unable/
208 / Journal of Cardiopulmonary Rehabilitation and Prevention 2015;35:207-213
www.jcrpjournal.com
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
JCRP-D-14-00084_LR 208
10/04/15 7:48 PM
unsafe) to 4 (independent/efficient/safe), with higher total scores indicating greater balance control. The BBS score has demonstrated internal consistency, intrarater and interrater reliability, content validity, construct validity, and predictive validity for determining fall risk in older adults.13 A cutoff score of 46 and less identifies those at risk of falling16,17 and age- and gender-specific scores are available in healthy populations.12
Unipedal Stance Test. Each patient’s ability to stand on one leg was assessed using the Unipedal Stance Test (UST). Patients selected the leg on which they preferred to stand for the test. They were instructed to keep their legs from touching and to maintain a unipedal stance for as long as possible. Failure to do so was defined as shifting the stance foot or placing the lifted foot on the floor. The UST was stopped and considered normal if a patient achieved 45 seconds using a unipedal stance.18 Although some investigators have used 30 seconds as a standard,19 Briggs and associates20 believed that a 45-second time limit would reduce any ceiling effect and provide a more normal distribution of times. Subjects were given 3 trials, unless they achieved 45 seconds on the first or second trial, and the greatest amount of time was recorded.
Tinetti test. The Tinetti test is a reliable clinical test for measuring balance and gait in older individuals. It has 16 items divided into 2 sections: balance (9 items) and gait (7 items), for a total score of 28. Individuals scoring
