Abstract
Purpose: Guidelines for pulmonary rehabilitation (PR) include balance training but lack specific parameters. After a knowledge translation project at our site, clinicians modified the physiotherapy programme to facilitate the sustainability of balance training as part of PR. The purpose of this study was to explore whether the modified programme resulted in improved balance and balance confidence. A secondary aim was to provide information on the way in which balance training was operationalized as part of PR for clinicians wanting to incorporate it into an existing PR programme. Method: We conducted a retrospective study of patients with chronic obstructive pulmonary disease, enrolled in a 4- to 6-week inpatient PR programme over a 1-year period. Balance training was provided biweekly with a staff-to-patient ratio of 2:11. Participants completed the brief Balance Evaluation Systems Test (brief-BESTest) and Activities-Specific Balance Confidence (ABC) scale at the beginning and end of PR. Results: The 85 participants had a mean age of 69.5 (SD 9.0) years. After completing an average of 7.6 balance sessions (min-max 2–13), participants showed improvements in brief-BESTest (mean difference 3.2 [95% CI: 2.5, 3.9] points) and ABC (mean difference 7.8 [95% CI: 4.1, 11.5] percent). Conclusions: A staff-to-patient ratio of 2:11 and a training frequency of twice per week for 4–6 weeks improved balance. This result will inform how we incorporate balance training into existing PR programmes.
Key Words: translational medical research, postural balance, program evaluation, pulmonary disease, chronic obstructive, rehabilitation
Abstract
Objectif : les directives relatives à la réadaptation pulmonaire (RP) incluent l’entraînement à l’équilibre, mais ne sont pas liées à des paramètres précis. Après un projet d’application des connaissances à l’établissement des cliniciens, ceux-ci ont apporté des modifications pour favoriser la pérennité de l’entraînement à l’équilibre en RP. La présente étude visait à explorer si le programme modifié améliorait l’équilibre et la confiance en l’équilibre. Un objectif secondaire consistait à fournir de l’information sur l’opérationnalisation de l’entraînement à l’équilibre dans le cadre de la RP chez les cliniciens qui désirent l’intégrer à des programmes de RP en place. Méthodologie : étude rétrospective des patients atteints d’une maladie pulmonaire obstructive chronique qui ont participé à un programme de RP de quatre à six semaines sur une période d’un an. L’entraînement à l’équilibre avait lieu deux fois par semaine selon un ratio de deux membres du personnel pour 11 patients. Les participants ont rempli le bref test sur les systèmes d’évaluation de l’équilibre (brief-BESTest) et l’échelle de confiance entre des activités précises et l’équilibre (ABC) au début et à la fin de la RP. Résultats : les 85 participants avaient un âge moyen de 69,5 ans (ÉT 9,0). Après avoir effectué en moyenne 7,6 séances d’équilibre (minimum de deux et maximum de 13), les participants se sont améliorés au brief-BESTest (différence moyenne de 3,2 points [IC à 95 % : 2,5, 3,9]) et à l’échelle ABC (différence moyenne de 7,8 % [IC à 95 % : 4,1, 11,5]). Conclusion : un ratio de deux membres du personnel pour 11 patients et une fréquence de deux entraînements par semaine pendant quatre à six semaines ont amélioré l’équilibre. Ce résultat éclairera l’intégration de l’entraînement de l’équilibre aux programmes de RP existants.
Mots-clés : : équilibre postural, évaluation du programme, maladie pulmonaire obstructive chronique, réadaptation, recherche médicale translationnelle
Chronic obstructive pulmonary disease (COPD) affects approximately 22% of Canadians aged 60–69 years and 37% of those aged 70–79 years.1 It is the fourth leading cause of death in Canada and is projected to be the fourth leading cause of death in the world by 2030.2,3 The primary impairments associated with COPD, which is a chronic lung disease, are shortness of breath, increased sputum production, and chronic cough.4 The secondary impairments are well established and include factors that affect balance, such as peripheral muscle dysfunction.4,5
The incidence of falls in people with COPD has been reported to be higher than in the general population of older adults (people with COPD are 55% more likely to have an incident record of fall than people without COPD)6 – a concerning finding given the potential consequences of falls such as injury, functional dependency, and death.7 Balance impairment is often identified as a modifiable risk factor for falls,8 and balance impairments have been shown to discriminate between fallers and non-fallers with COPD.9 Despite these important findings, pulmonary rehabilitation (PR), the standard of care for people with COPD,4,10 is insufficient to improve balance;11 therefore, guidelines for PR now include balance assessment and balance-specific training as part of the exercise programme.12 Yet, to our knowledge, few programmes include balance training as a standard part of PR.
A randomized controlled trial (RCT) of balance training that was incorporated into PR showed promising results for improving balance in people with COPD.13 The participants who completed PR plus balance training showed substantially higher scores on balance measures than those receiving PR alone.13 Despite the fact that RCTs provide a high level of evidence of effectiveness, the strict inclusion criteria for enrolment and the controlled environments in which they occur may compromise their external validity.14 Because it often takes many years for published research to be adopted into practice,15 knowledge translation (KT) interventions are increasingly being used16 to increase clinicians’ and patients’ familiarity with the research findings and to inform their decision making.
A KT study to implement balance training in PR was conducted at our health care centre after the success of an initial balance RCT.13,17 The participants had statistically and clinically significant improvements in balance, as well as improvements in the standard PR outcome measures of functional capacity and disease-specific health-related quality of life, which were comparable to those obtained in the RCT.13,17 After the KT intervention, the clinicians involved in the balance training modified its parameters to facilitate its sustainability by holding fewer sessions per week and using a substantially lower staff-to-patient ratio. The purpose of this study was to explore whether the modified programme resulted in improved balance and balance confidence. A secondary aim was to provide information on the way in which balance training was operationalized as part of PR for clinicians looking to incorporate balance training into existing PR programmes.
Methods
This study was approved by the Joint West Park Healthcare Centre/Salvation Army/Toronto Grace Health Centre Research Ethics Board (REB). Explicit participant consent was not required by the REB because of the scope and retrospective nature of the study.
Participants
We collected data retrospectively on consecutive patients admitted to inpatient PR over a 1-year period (September 1, 2014–August 31, 2015). The inclusion criteria for this retrospective analysis were as follows: (1) the patient had to be diagnosed with COPD according to the Global Initiative for Chronic Obstructive Lung Disease criteria and (2) the patient had to have completed the measure of balance at the beginning and end of the rehabilitation programme.4 All participants who met these criteria were included regardless of their fall history or disease severity. We anonymized the data from their medical charts when they were entered into the study database.
Measures
All participants completed the brief Balance Evaluation Systems Test (brief-BESTest),18 Activities-Specific Balance Confidence (ABC) scale,19 6-minute walk test (6MWT),20 and Chronic Respiratory Disease Questionnaire (CRQ)21 when they were admitted to PR and when they were discharged 4–6 weeks later. Their primary physiotherapist provided the questionnaires and administered the 6MWT and brief-BESTest.
Brief Balance Evaluation Systems Test
The brief-BESTest is a six-item physical balance measure that is based on the systems framework and assesses six components of balance: biomechanical constraints, stability limits, transitions–anticipatory postural adjustment, reactive postural response, sensory orientation, and stability in gait. The six items are scored on a scale ranging from 0 to 3, and two of the six items are scored bilaterally for a maximum possible score of 24 points. A higher score represents better balance. The test has high inter- and intra-rater reliability and the ability to differentiate between fallers and non-fallers in people with COPD.22 The minimal detectable change (MDC95) in people with COPD is 1.88 points.23
Activities-Specific Balance Confidence scale
The ABC scale is a 16-item self-report questionnaire on which respondents rate their confidence in not losing their balance or becoming unsteady when they complete a variety of tasks. The responses range from 0% to 100% for each item and are averaged to produce a final percentage. Higher scores mean a higher level of confidence. The ABC scale is able to distinguish among various levels of functional ability and is responsive to balance training in older adults.24 A change of 19 points is required for the change in balance to be both perceptible to participants and beyond measurement error in people with COPD.25
6-Minute Walk Test
To complete the 6MWT, participants were asked to walk back and forth along a 30-metre indoor corridor, covering as much distance as they could in 6 minutes. The total distance is reported in metres; higher distances indicate better functional capacity. The 6MWT has good construct validity and test–retest reliability, and it is responsive to exercise interventions in people with chronic lung disease.26 The minimal clinically important difference (MCID) for the 6MWT in people with COPD is 25 metres.27
Chronic Respiratory Disease Questionnaire
The CRQ is a disease-specific health-related quality of life questionnaire that provides scores in four dimensions: dyspnea (five items; participants completed the standardized rather than individualized dyspnea domain version), fatigue (four items), emotion (seven items), and mastery (four items). Respondents score each question on a 7-point scale; higher scores indicate better health-related quality of life. The self-administered CRQ has good convergent validity when compared with other quality of life measures, and it is sensitive to changes in health status in people with chronic respiratory disease.28 The MCID is 0.5 points for each item.29
Pulmonary rehabilitation
The inpatient PR programme is 6 weeks long, although participants admitted for a repeat course may complete an abbreviated programme of 4 weeks. The programme runs Monday to Friday and consists of both education and exercise. There are five multidisciplinary education sessions per week, focusing on topics such as anxiety and stress management, pills and puffers, and body mechanics. There are two exercise sessions per day (10/wk), which last for a maximum of 90 minutes. After being assessed by their primary physiotherapist, each participant is prescribed an individualized exercise programme, which may include any combination of resistance training (hand weights or exercise bands), walking (treadmill or ground), cycling (upright or recumbent), stepping (recumbent), and general mobility and functional exercises.
This PR programme is consistent with that completed by the participants in both the RCT and KT balance studies conducted at our centre, except that participants in those studies were recruited from both the inpatient and the outpatient PR programmes. The outpatient programme consists of the same components but, at the time of those studies, was delivered 3 days per week for 12 weeks.
Balance training
During the KT study conducted at our centre, balance training was offered three times per week for 30 minutes per session with a staff-to-patient ratio of 1:3 for patients who had a history of falls or reported balance problems.17 Balance sessions replaced three of the usual PR exercise sessions for those patients participating in the study. Balance training was conducted concurrently with the usual PR exercise sessions, meaning that as many as 13 additional patients were in the room doing non-balance exercises with the support of one additional staff member. Often, one extra clinician was required for 30 minutes three times a week, which translates to an additional 0.05 full-time equivalent position.17
After the KT study, the clinicians who had been involved in the balance training identified certain barriers to the long-term sustainability of the balance training in its current format. These concerns resulted in changes to the operationalization of balance training by the clinical staff to create what they believed would be a more sustainable balance training programme.
The modified balance training occurred two times per week (replacing two usual PR exercise sessions) over 4–6 weeks with a staff-to-patient ratio of as much as 2:11. During a focus group at the end of the KT study, the clinicians expressed the opinion that there was not enough time to prescribe balance training in addition to the other components of the PR programme such as resistance training and cardiovascular endurance circuit training, and they were concerned that the high number of balance sessions would not give patients sufficient treatment time to progress in the non-balance exercises.17 They believed that dedicating two exercise sessions per week to balance training would have a less negative impact on the other aspects of the programme.
The clinicians also said that it was difficult to supervise balance training while concurrently supervising patients engaged in other PR exercises.17 To eliminate this barrier, they opted to provide balance training to all patients in the inpatient programme rather than to only those with a history of falls or balance problems. This lower staff-to-patient ratio was achievable because the patients were provided with exercise logs (see the Appendix) and pictures of the exercises and were for the most part expected to complete the exercises independently. The length of the balance session depended on each participant’s programme but was at most 45 minutes. Balance exercises were individualized and prescribed by each participant’s primary physiotherapist on the basis of the individual’s performance on the brief-BESTest during the pre-PR assessment. Table 1 describes the six subsections of the brief-BESTest, and Table 2 presents the similarities and differences between the KT balance training and the modified programme.
Table 1.
Description of the Subsections of the Brief-BESTest
| Subsection | Description | Example exercise |
|---|---|---|
| Anticipatory postural adjustment | Tasks that require active movement of the COM in anticipation of a transition from one position to another | Single leg stance |
| Sensory orientation | Tasks that alter visual or somatosensory information | Narrow stance on unstable surface with eyes closed |
| Stability in gait | Tasks that challenge balance during gait | Tandem walk |
| Biomechanical constraints | Tasks that target functional ankle and hip strength | Step-ups |
| Stability limits | Tasks that target the internal representation of how far the body can move before changing the BOS or losing balance | Forward reach, standing |
| Reactive postural response | Tasks that target in-place and compensatory stepping responses to an external perturbation | Lean and release to elicit a stepping response, forward |
brief-BESTest = brief Balance Evaluation Systems Test; COM = centre of mass; BOS = base of support.
Table 2.
Operationalization of Balance Training during KT Study and Modified Programme
| Parameter | KT study | Modified programme |
|---|---|---|
| Frequency | 3d/wk | 2d/wk |
| Duration | 30 min/session | ~45 min/session |
| Staff-to-patient ratio | 1:3 | 2:11 |
| Prescription method | On the basis of the brief-BESTest, pre-set list of exercises combining all 6 subsections with 3 levels of difficulty; exercises led by physiotherapist in a small group setting | On the basis of the brief-BESTest, pre-set list of exercises for each subsection and a description and pictures of exercises given to participants; completed independently in a large group setting |
| Participants | Inpatients and outpatients with a history of falls or balance problems | All inpatients |
KT = knowledge translation; brief-BESTest = brief Balance Evaluation Systems Test.
The clinicians who worked in the inpatient programme at the time and conducted the balance training for the KT study as well as for the modified programme were one rehabilitation assistant and four physiotherapists. One of the physiotherapists had previously conducted balance assessment research and authored this study (SO), and all the clinicians had participated in a 1-hour training session for the KT study, which described the benefits and applications of balance training and provided hands-on practice with the balance equipment.17
Statistical analyses
We explored the data for normality using histograms and Shapiro–Wilk tests. The descriptive data were reported as mean (SD) or median (25th–75th percentile). To examine within-group differences from pre-PR to post-PR, we used paired t-tests or Wilcoxon signed-rank tests. All statistical analyses were conducted using STATA, Version 14.2 (StataCorp LLC, College Station, TX), and a p-value < 0.05 was considered significant.
Results
Of the 151 patients admitted to inpatient PR during the retrospective study period, 108 (71.5%) had a primary respiratory diagnosis of COPD; as a result, 43 were excluded. Another 23 patients did not have balance assessment data (see Figure 1). We found no differences between people with and without balance assessment data on any characteristic (mean age 69.5 and 70.1 years, respectively, p = 0.78; 47.1% and 56.5% female, respectively; p = 0.42), baseline exercise capacity (mean 6MWT score of 270.0 and 251.5 m, respectively; p = 0.48), or health-related quality of life (mean CRQ score of 14.4 and 13.8 points, respectively; p = 0.61). A total of 85 participants with a mean age of 69.5 (SD 9.0) years were included, of whom 45 (52.9%) were men. See Table 3 for additional participant characteristics.
Figure 1.
Flow diagram showing the selection process.
Table 3.
Participant Characteristics (N = 85)
| Characteristic | Mean (SD)* |
|---|---|
| Age, y | 69.5 (9.0) |
| Male, no. (%) | 45 (52.9) |
| BMI, kg/m2, median (25th–75th percentile) | 25.6(21.6–31.4) |
| FEV1 % predicted, median (25th–75th percentile) | 32.0 (22.0–48.0)† |
| FEV1/FVC, median (25th–75th percentile) | 38.0(31.0–48.0)† |
| Use of gait aid, no. (%) | 60 (70.6) |
| Use of supplemental oxygen, no. (%) | 36 (42.3) |
| Balance sessions completed | 7.6 (2.2)‡ |
| Total PR exercise sessions completed | 39.3 (8.6)‡ |
| Baseline brief-BESTest score, 0–24 | 14.4(6.0) |
| Baseline ABC score, 0–100, median (25th–75th percentile) | 70 (50.0–81.3)§ |
Unless otherwise specified. Sample size lower for some data as it could not be located in all participant records.
n = 75.
n = 82.
n = 69.
FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity; PR = pulmonary rehabilitation; brief-BESTest = brief Balance Evaluation Systems Test; ABC = Activities-Specific Balance Confidence scale.
The subsections of the brief-BESTest on which participants scored lowest during the initial assessment were anticipatory postural adjustment (mean 1.5 [SD 0.9] points averaged between the left and right sides), biomechanical constraints (mean 1.5 [SD 0.6] points), and reactive postural response (mean 1.9 [SD 1.1] points, averaged between the left and right sides). However, the most frequently prescribed exercises were in the categories of anticipatory postural adjustment (73 of 83; 88.0%), sensory orientation (57 of 83; 68.7%), and stability in gait (56 of 83; 67.5%). Reactive postural response exercises were least commonly prescribed (16 of 83; 19.3%). We were unable to find details on the prescribed balance exercises for two participants. See Table 4 for details.
Table 4.
Most Commonly Prescribed Exercises by Subsection of brief-BESTest
| Subsection | No. (%) |
||
|---|---|---|---|
| Exercise 1 | Exercise 2 | Exercise 3 | |
| Anticipatory postural adjustment (n = 73 participants) | Single leg stance; 59 (80.8) | Step tap; 57 (78.1) | Tandem stance; 56 (76.7) |
| Sensory orientation (n = 57) | Narrow stance on foam, eyes closed; 35(61.4) | Narrow stance on foam, eyes open; 24(42.1) | Standing on incline ramp, eyes closed; 19 (33.3) |
| Stability in gait (n = 56) | Tandem walk; 48 (85.7) | Backward walk and side step; 36 (64.3) each | Toe walking; 28 (50.0) |
| Biomechanical constraints (n = 52) | Step-ups; 47 (90.4) | Lateral step-ups; 40 (76.9) | Calf raises; 32 (61.5) |
| Stability limits (n = 31) | Forward reach, standing; 24 (77.4) | Sideways reach, standing; 19 (61.3) | Sideways reach, sitting; 12 (38.7) |
| Reactive postural response (n = 16) | Stepping response, forward and side; 12 (75.0) each | Stepping response, backward and in place, narrow stance; 9 (56.3) each | In place, tandem stance; 4 (25.0) each |
brief-BESTest = brief Balance Evaluation Systems Test.
With PR, the group showed improvements in balance (within-group brief-BESTest mean difference of 3.2 points [95% CI: 2.5, 3.9]) and balance confidence (within-group ABC scale mean difference of 7.8 [95% CI: 4.1, 11.5]; see Table 5). The subsections of balance that improved the most were biomechanical constraints (within-group mean difference of 0.66 points [95% CI: 0.47, 0.86]), sensory orientation (within-group mean difference of 0.45 points [95% CI: 0.31, 0.58]), and anticipatory postural adjustment (within-group mean difference of 0.38 points [95% CI: 0.23, 0.52], averaged between the left and right sides).
Table 5.
Outcomes before and after Pulmonary Rehabilitation
| Mean (SD) |
|||
|---|---|---|---|
| Test* | Before | After | Difference (95% CI) |
| brief-BESTest | 14.4(6.0) | 17.6(5.7) | 3.2 (2.5,3.9) |
| ABC scale† | 64.3 (22.2) | 72.1 (19.8) | 7.8(4.1,11.5) |
| 6MWT‡ | 270.0(110.7) | 329.3(101.5) | 59.3 (44.7,73.9) |
| CRQ§ | 14.4(4.6) | 19.9(3.8) | 5.5 (4.5,6.4) |
Sample size lower for some tests because it could not be located in all participant records.
n = 69.
n = 83.
n = 71.
brief-BESTest = brief Balance Evaluation Systems Test; ABC = Activities-Specific Balance Confidence; 6MWT = 6-minute walk test; CRQ = Chronic Respiratory Disease Questionnaire.
The participants also showed improvements in the usual measures of PR effectiveness, CRQ and 6MWT (within-group mean differences of 5.5 points [95% CI: 4.5, 6.4] and 59.3 metres [95% CI: 44.7, 73.9], respectively; see Table 5). All within-group changes were significant at p < 0.001. More than 85% of the participants thought that their balance was “a little better” or “much better” at discharge compared with admission to PR.
Discussion
In this study, we found that a modified balance training programme of two sessions per week with a staff-to-patient ratio of as much as 2:11 implemented as part of PR resulted in improvements in balance and balance confidence. These findings are informative for clinicians who want to include balance training in their PR programmes. Adopting clinical interventions after KT studies can be challenging because of several factors, including the absence of a local champion, lack of ongoing education, and competing staff or patient priorities.30,31 Therefore, long-term follow-up is necessary to know whether interventions have continued to be delivered in the original way and, if not, whether interventions modified to facilitate long-term implementation are able to produce similar outcomes.
After the KT balance intervention, at 6-month follow-up, the intervention was not being delivered as originally planned so that the clinicians could facilitate its long-term implementation.17 Despite the changes made to the operationalization of balance training in PR, the participants still showed improvements in balance, balance confidence, quality of life, and functional capacity.
The participants showed improvements in CRQ and 6MWT that exceeded the MCIDs for those measures,27,29 thereby confirming that adding balance training did not have a negative impact on the usual measures of PR effectiveness. The magnitude of improvement on these measures was similar to what was observed in the KT study, although slightly lower: a CRQ mean change of 5.5 (SD 4.1) points compared with 7.0 (SD 4.0) points in the KT group and a 6MWT mean change of 59.3 (SD 66.9) metres compared with 63.3 (SD 35.9) metres in the KT group.17
The improvement in brief-BESTest scores was greater than the MDC95,23 suggesting that the observed changes were beyond measurement error. The improvement of three points represented an improvement of 21%, but in the absence of an MCID for this test, we cannot comment on whether this within-group improvement was clinically important. However, the majority of participants self-reported that their balance had improved. The magnitude of improvement in balance was, again, slightly lower in this group than in the KT group: a mean change of 3.2 (SD 3.3) points compared with 4.7 (SD 3.7) points in the KT group (unpublished data).17 This may have been due to the difference in the number of balance sessions completed by the two groups; the KT group completed an average of 11.9 sessions, and the modified training group completed an average of 7.6 sessions.
The ABC scores did not show a meaningful improvement;25 this is consistent with both the RCT of balance training conducted at our centre as well as the KT study.13,17 A 6-month balance training programme has been shown to improve balance confidence,32 suggesting that a longer intervention might be necessary to detect meaningful improvements in balance confidence.
Despite current PR recommendations to include balance training as a component of exercise, recommendations regarding the specific type, frequency, and volume of balance training are lacking. Our training emphasized anticipatory postural adjustments, stability in gait, and sensory orientation. It is not surprising that anticipatory exercises were frequently prescribed, given that this type of balance is often assessed by physiotherapists and includes common balance exercises such as tandem stance and single-leg stance.33 Two other components on which participants had low test scores, biomechanical constraints and reactive postural response, were not specifically targeted, the first likely because biomechanical constraints (such as step-ups and squats) are usually included in PR as part of patients’ resistance training programmes. Training on reactive postural response (i.e., perturbation training) would have required one-to-one training, so exercises in this domain may have been less commonly prescribed as a result of the low staff-to-patient ratio.
The brief-BESTest subsections on which participants showed the greatest improvement in scores were biomechanical constraints, sensory orientation, and anticipatory postural adjustments. This is unsurprising given the focus on resistance training in the usual PR exercise programme and the focus on the latter two subsections in the balance training programme. Specificity is one principle of exercise training that is well established in the resistance and endurance training literature;34 it has also been shown in balance training for healthy people, with participants improving only in the balance task that was trained.35 This lack of a carry-over effect emphasizes the importance of training the specific systems of balance in which participants are impaired. For this group, more focus on reactive postural response exercises such as perturbation training may have resulted in greater improvement in that area.
Current recommendations for balance training for persons with COPD as well as for the general populations of older adults call for a minimum of three sessions per week, each lasting 30 minutes.13,36 When this frequency of training is not feasible, targets for total volume of training need to be identified. Without specific data on the duration of sessions, and because each participant had an individualized programme, it is difficult to identify the total volume of training that was completed by this cohort. However, sessions lasted up to 45 minutes, which would offer a total training time of 90 minutes, which is comparable to completing a 30-minute session three times per week.
In this study, balance training was provided to COPD patients undergoing PR regardless of their falls history; this likely resulted in an underestimation of the impact of training on those prone to falling. However, given their average age of 70 years, many participants would have had at least one risk factor for falls and would therefore benefit from balance training, in keeping with falls prevention programmes offered to older adults.37 Therefore, these observations are likely generalizable to most older adults with COPD.
This study had some limitations. First, data for some participants were incomplete; however, given that there were no significant differences at baseline between those included and those not included in the analyses, it is unlikely that this had an impact on our results. Second, because of the retrospective study design, we were unable to report information such as total volume of training, adherence to balance training after PR, or long-term maintenance of outcomes. Third, this study was carried out in an inpatient PR programme and may not be generalizable to outpatient programmes. Finally, given the retrospective nature of the study and some of the characteristics of the programme, we were unable to use a KT framework such as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) to explore the modified programme and present the results from an implementation and sustainability perspective.38,39 Using such a framework would have allowed us to carry out a more structured analysis and would have provided more detail for clinicians wanting to adopt balance training in PR.
Conclusion
To summarize, it is possible to provide effective balance training for older adults with COPD as part of PR using a staff ratio of up to 2:11 and a training frequency of twice per week for 4–6 weeks. Given the positive impact of this training, this larger group format may be an option for clinicians who follow guidelines that recommend balance training as part of PR, although longer-term sustainability remains to be established. The brief-BESTest can be used to assess baseline balance performance, to guide treatment by targeting specific balance systems, and to measure change over time. For patients who require perturbation training to improve reactive postural response and for those who are prone to falling, additional staff support may be needed.
Key Messages
What is already known on this topic
People with chronic obstructive pulmonary disease experience secondary impairments beyond their respiratory symptoms, including balance impairments, which discriminate between fallers and non-fallers. Preventing falls is important, and balance-specific training is recommended as part of pulmonary rehabilitation (PR). However, descriptions of how it can be included in PR programmes are scarce.
What this study adds
This retrospective study examined the actual implementation of balance training within the resource base of a PR programme in which group sessions enabled participants to complete an average of 7.6 balance training sessions over 4–6 weeks. The systems of balance that were most frequently targeted in the training were anticipatory postural adjustments, sensory orientation, and stability in gait. In addition to the improvements in objective measures of balance and balance confidence, more than 85% of the participants reported that their balance was “a little better” or “much better” at the end of training.
APPENDIX: Example of an Individual Exercise Record
Anticipatory Postural Adjustment
| Date: | Feb26 | |||
|---|---|---|---|---|
| 1. Sit to stand | 5 × | ✓ | ||
| 2. Shoulder check | 3 × each side | ✓ | ||
| 3. Forward/back weight shift | ||||
| 4. Lateral weight shift | ||||
| 5. Slow march | ||||
| 6. Tandem stance | 10 s each side | ✓ | ||
| 7. Single leg stance | 10 s each side | ✓ | ||
| 8. Alternating step tap | ||||
| 9. Alternating forward lunge | 3 × each side | ✓ | ||
| 10. Alternating backward lunge | ||||
| 11. Alternating sideways lunge | ||||
| 12. Alternating diagonal lunge | ||||
| 13. Kick ball | ||||
| 14. Throw ball | 5 × | ✓ |
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