4. DISCUSSION
Although balance impairment in patients with COPD seems to be less
important than the other life-threatening symptoms of this disease, the
fall and fractures resulting from the balance impairment may lead to a
decrease in the quality of life and an increase in morbidity and
mortality. Recent studies have shown that balance impairment and falls
are frequent in patients with COPD.1,20 Numerous tests
ranging from simple clinical tests to more complex tests conducted using
diverse devices in the laboratory environment have been utilized to
evaluate the balance issues in patients. The decision regarding which
test should be used has changed with time, conditions, and personal
experiences.21-23 Studies on balance have generally
been performed among the elderly, post-operative patients, post-stroke
term, and rheumatic disease patients. However, the number of studies
investigating balance issues in patients with COPD is low, and even
these studies have investigated a small cohort of patients and utilized
only a small portion of balance assessment tests. In pulmonary diseases
outpatient clinic, it would be more appropriate for the physicians to
select easy-to-perform balance assessment tests to enable focusing on
the underlying primary disease for the treatment of patients with COPD
who are considered to have balance impairment should be evaluated with
the shorter tests at first presentation, and these patients should be
directed and evaluated in pulmonary rehabilitation. Hence, patients
should be evaluated with more complicated tests to reveal the problem in
balance mechanism in order to plan and implement a rehabilitation
program accordingly.
BBS is the gold standard in balance assessment and also one of the most
frequently applied tests for assessing balance in patients with COPD.
Recent studies have shown that patients with COPD have significantly
lower BBS scores than the normal population.1,5 In our
study, we found that 32 (45.1%) of the patients with COPD had balance
impairment as per the BBS test. However, since it takes approximately 15
min to perform the BBS test, it is difficult to perform it daily in the
complex environment of an outpatient clinic.6
The past studies assert that SLS test is one of the most frequently
employed tests for the assessment of balance impairment in patients with
COPD, with more balance impairment detected by SLS in patients with COPD
relative to that in control subjects.24-26 In our
study, SLS test could detect balance impairment in 57 (80.3%) of the
patients with COPD. However, when compared to the BBS test, SLS test
could detect balance impairment in more number of patients, indicating
that SLS is less selective than BBS.
In our study, we detected balance impairment in 66 (92.9%) of the
patients with COPD by using the 5STS test. The comparative rate was 50%
in the control group. This difference may be attributed to the fatigue
of weakened quadriceps muscles in patients with COPD after 5 times of
“sitting down and standing up” sequence that extends the times
required to finish the test. Since this test has low selectivity with
respect to assessing balance impairment in patients with COPD, we
suggest that other tests should be performed before STS to eliminate
non-essential steps.
We detected balance impairment in 49 (69%) of our patients by using the
FSST test. The reason for the greater frequency of detection relative to
that by BBS can be the difficulty in comprehending the FSST test.
However, the results of FSST are more consistent with BBS in terms of
detecting balance impairment when compared to SLS and 5STS. FSST had the
second highest correlation with BBS. In addition, while BBS requires 15
min for completion, FSST can be completed in 5 min, which favors the
preference for the latter.
In our study, balance impairment was detected in 38 (53.5%) of the
patients with TUG test. Among all the tests, TUG gave the closest
results with BBS in terms of detecting balance impairment. Morover TUG
had the highest correlation with BBS. This test evaluates patients in 3
stages. The test first evaluates the quadriceps muscles when the patient
stands up from the chair and sits; this muscle is the most-affected
peripheral muscle group in patients with COPD. In the next 2 stages, the
balance impairment observed during the daily life activities is
evaluated by walking the patient for 3-m (10 ft) and back. Thus, the
static and dynamic balances are evaluated by this test. Hence, we
believe that this test can produce more objective results in patients
with COPD in comparison with other easy-to-perform tests.
SLS and 5STS can evaluate static balance, while TUG and FSST can
evaluate both static and dynamic balances. We believe that it would be
more accurate to evaluate dynamic balance together with static balance
when evaluating the balance issue in patients with COPD, since
evaluation of only the static balance will bypass maneuvers that
maintain balance during a regular gait. In our study, the closest
results to BBS were obtained with TUG and FSST.
In our study, balance impairment and fall history in Group C and D
patients with COPD were more frequent than those in Group A and B. COPD
exacerbations negatively affect the muscle functions and physical
activity levels. As a result, the incidence of fall
increased.27 Since Groups C and D had higher frequency
of exacerbation, these groups showed more balance impairment and an
increased incidence of falls in both the groups.
The risk of balance impairment and falls in patients with COPD are not
considered very important by healthcare professionals and patients.
However, in our study, we observed that balance impairment and frequency
of falls increased in patients with COPD and that the balance test
scores could be correlated with functional parameters such as patient’s
pulmonary function test parameters, CAT, mMRC, and BODE scores. In this
case, we speculate that evaluating patients with COPD with balance tests
is a useful approach toward determining balance impairment and risk of
falls and for predicting the functional status.
The main limitation of our study was that we did not use the BES and
Activities Specific Balance Confidence Scale with BBS in the comparison
assessment with SLS, 5STS, FSST, and TUG tests. The former tests are
more detailed for the evaluation of balance. However, since all of these
3 tests are relatively more time consuming to apply simultaneously, BBS,
which is the most frequently used test, was preferred in this study.