Balance, falls, and risk of falls in COPD: systematic review of assessment instruments, measurement properties, and clinical utility

Lamezon, Ana Cristina; Cavon, Bruna Luna; Valderramas, Silvia

doi:10.1590/1981-22562024027.230189.en

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Revista Brasileira de Geriatria e Gerontologia

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Sumário

Review Articles • Rev. bras. geriatr. gerontol. 27 • 2024 • https://doi.org/10.1590/1981-22562024027.230189.en copy

Balance, falls, and risk of falls in COPD: systematic review of assessment instruments, measurement properties, and clinical utility

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

to identify balance assessment instruments, issues and risks of issues used in COPD, evaluate their measurement properties, quality of evidence and clinical utility.

Method

A review was produced following the PRISMA and COSMIN guidelines, registered in PROSPERO: CRD42021235118. Searches were carried out from November 2021 to September 2022 in the PubMed, LILACS, CINAHL, Embase, Web of Science and PEDro databases. Cross-sectional and cohort observational studies were included, without restrictions on language or year of publication, as long as they described clinical instruments for assessing balance, falls and risk of falls reporting at least one of the measurement properties: validity, reliability and responsiveness. Two reviewers will independently apply the eligibility criteria, travel risk by COSMIN, quality of evidence by the GRADE approach and assessment of clinical utility by the Tyson and Connell Scale.

Results

9,102 studies were selected and 21 included in the review, nine studies demonstrated adequate and sufficient measurement properties and 12 instruments were identified, of which six were evaluated for the quality of evidence.

Conclusion

Systematic reviews of measurement properties require specialized reviewers and skills in qualitative analysis. With a recommendation GRADE of “A”, the Berg Balance Scale (BBS) and the Timed Up and Go (TUG) test were the most recommended instruments for COPD. By requiring the evaluation of the clinical utility of the result, the TUG demonstrates superiority to the BBS, proving to be a great tool for judging individuals who need a thorough assessment of balance, falls and risk of falls.

Keywords
Chronic Obstructive Pulmonary Disease; Balance; Falls; Risk of falls; Measurement properties

Studies	COPD (n)	M (n)	F (n)	COPD Sta (n)	COPD Exa (n)	Contr (n)	Age (years)	Smo (a/m)	O₂ Sup (n)	FEV₁ (%pred)	Falls 12m (n)
Mclay et al.²¹21 McLay R, Kirkwood RN, Kuspinar A, Richardson J, Wald J, Raghavan N, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chronic Respiratory Disease[Internet]. 2020;17. Disponível em: https://doi.org/10.1177/1479973120922538 https://doi.org/10.1177/1479973120922538... ,	86	45	41	86	0	0	72.9(±6.8)	46.0(±27.0)	25(±29.1)	47.3(±20.3)	34
Crisan et al.²²22 Crişan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD. PloS one [Internet]. 2015;10(3): e0120573. Disponível em: https://doi.org/10.1371/journal.pone.0120573 https://doi.org/10.1371/journal.pone.012... ,	46	NM	NM	29	17	0	62.5(±5.0)	>10	NM	NM	17
Jacome et al.²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391 https://doi.org/10.2522/ptj.20150391... ,	46	24	22	46	0	0	75.9 (±7.1)	NM	NM	69.4(±19.9)	23
Oliveira et al. ²⁴24 Oliveira CC, McGinley J, Lee AL, Irving LB, Denehy L. Fear of falling in people with chronic obstructive pulmonary disease. Respir Med[Internet]. 2015;109(4):483-9. Disponível em: https://doi.org/10.1016/j.rmed.2015.02.003 https://doi.org/10.1016/j.rmed.2015.02.0... ,	40	19	21	40	0	25	71(±8.1)	49.6 (±25.8)	18	45.1(±16.2)	13
Ozalevli et al. ²⁵25 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 Clinical and Experimental Research[Internet]. 2011;23(5-6):372–7.Disponível em: https://doi.org/10.1007/bf03325235 https://doi.org/10.1007/bf03325235... ,	36	25	11	36	0	20	70.3(±3.0)	42.1(±11.2)	NM	43.5(±6)	10
Voica et al.²⁶26 Voica A ,Oancea C, Tudorache E, Crisan A, Fira-Mladinescu O, Tudorache V, et al. Chronic obstructive pulmonary disease phenotypes and balance impairment. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2016; 11(1):919-925. Disponível em: https://doi.org/10.2147/COPD.S101128 https://doi.org/10.2147/COPD.S101128... ,	27	NM	NM	27	0	17	NM	>10	NM	NM	NM
Nantsupawat et al.²⁷27 Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207 https://doi.org/10.1177/2150131915577207... ,	14	8	6	14	0	0	69.7(±6.0)	NM	3(±21.4)	36.9(±.6)	3
Muti et al.²⁸28 Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752 https://doi.org/10.3390/jcm8101752... ,	50	NM	NM	50	0	0	66.2(±8.2)	NM	NM	51.8(±15.9)	23
Porto el al. ²⁹29 Porto EF, Pradella CO, Rocco CM, Chueiro M, Jr., Maia RQ, Ganança FF, et al. Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2017;37(2):139–45. Disponível em: https://doi.org/10.1097/HCR.0000000000000246 https://doi.org/10.1097/HCR.000000000000... ,	132	72	60	132	0	39	67.3(±10)	49.1(±23)	NM	89.2(±23.6)	35
Hellstrom et al.³⁰30 Hellström K, Vahlberg B, Urell C, Emtner M. Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease. Clinical Rehabilitation[Internet]. 2009;23(12):1136–44. Disponível em: https://doi.org/10.1177/0269215509342329 https://doi.org/10.1177/0269215509342329... ,	80	29	51	80	0	0	65(±9.0)	NM	NM	47.5(±13)	20
Park et al.³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609 https://doi.org/10.3390/jcm9020609... ,	34	14	20	34	0	22	68.9(±1.3)	NM	20	44.1(±3.1)	21
Mkacher et al.³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240 https://doi.org/10.1097/HCR.000000000000... ,	60	NM	NM	60	0	0	61.2(±3.2)	0	NM	58.6(±8.6)	NM
Beauchamp et al.⁸8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311 https://doi.org/10.1177/1479973118820311... ,	39	18	21	39	0	0	71.1(±6.8)	>10	18	41.5(±17)	18
Al Haddad et al.³³33 Al Haddad MA, John M, Hussain S, Bolton CE. Role of the Timed Up and Go Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention[Internet]. 2016;36(1):49–55. Disponível em: https://doi.org/10.1097/hcr.0000000000000143 https://doi.org/10.1097/hcr.000000000000... ,	132	74	62	132	0	58	68(±8.0)	46.0(±26)	NM	59(±18)	27
Singh et al.³⁴34 Singh SS, Bhat A, Mohapatra AK, Manu MK, Vaishali K. Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants. Heart & Lung[Internet]. 2019; Disponível em: https://doi.org/10.1016/j.hrtlng.2019.09.006 https://doi.org/10.1016/j.hrtlng.2019.09... ,	41	38	3	41	0	41	NM	NM	0	47.6(±17.9)	NM
Pereira et al.³⁵35 Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427 https://doi.org/10.1097/HCR.000000000000... ,	70	46	23	70	0	0	67(±9.3)	56.0 (±38.2)	0	42.7(±14.2)	29
Harrison et al.³⁶36 Harrison SL, Beauchamp MK, Sibley K, Araujo T, Romano J, Goldstein RS, et al. Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease. BMC Pulmonary Medicine[Internet]. 2015;15(1).Disponível em: https://doi.org/10.1186/s12890-015-0067-2 https://doi.org/10.1186/s12890-015-0067-... ,	32	17	15	32	0	0	68.5(±9.9)	62.3 (±30.4)	NM	38.2(±14.7)	NM
Roig et al.¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022 https://doi.org/10.1016/j.rmed.2009.03.0... ,	20	NM	NM	20	0	20	72.3(±6.7)	NM	0	46.7(±13.0)	4
Roig et al.³⁷37 Roig M, Eng JJ, MacIntyre DL, Road JD, FitzGerald JM, Burns J, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respiratory medicine [Internet]. 2011;105(3):461–9. Disponível em: https://doi.org/10.1016/j.rmed.2010.08.015 https://doi.org/10.1016/j.rmed.2010.08.0... ,	101	56	45	101	0	0	NM	NM	31	43.4(±36.9)	32
Tudorache et al.³⁸38 Tudorache E, Oancea C, Avram C, Fira-Mladinescu O, Petrescu L, Timar B. Balance impairment and systemic inflammation in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2015; 10(1):1847-1852. Disponível em: https://doi.org/10.2147/copd.s89814 https://doi.org/10.2147/copd.s89814... ,	61	NM	NM	22	19	20	60(±4.0)	>20	0	27.5(±7.0)	NM
De Castro et al.³⁹39 de Castro LA, Ribeiro LR, Mesquita R, de Carvalho DR, Felcar JM, Merli MF, et al. Static and Functional Balance in Individuals With COPD: Comparison With Healthy Controls and Differences According to Sex and Disease Severity. Respiratory care [Internet]. 2016;61(11):1488–96. Disponível em: https://doi.org/10.4187/respcare.04749 https://doi.org/10.4187/respcare.04749... ,	72	27	20	47	0	25	68(±5.0)	NM	NM	45(±15)	NM

Study	Year	Content Validity	Construct Validity	Internal Cons.	Transcul.Validity	Reliab.	Measure Error	Criterion Validity	Hypot. Test	Respons.	Final Class.
Mclay et al.²¹21 McLay R, Kirkwood RN, Kuspinar A, Richardson J, Wald J, Raghavan N, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chronic Respiratory Disease[Internet]. 2020;17. Disponível em: https://doi.org/10.1177/1479973120922538 https://doi.org/10.1177/1479973120922538... ,	2020	A/+	N/I	N/I	N/I	N/I	N/I	N/I	O/+	N/I	A/+
Harrison et al.³⁶36 Harrison SL, Beauchamp MK, Sibley K, Araujo T, Romano J, Goldstein RS, et al. Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease. BMC Pulmonary Medicine[Internet]. 2015;15(1).Disponível em: https://doi.org/10.1186/s12890-015-0067-2 https://doi.org/10.1186/s12890-015-0067-... ,	2019	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	A/-	A/-
Voica et al.²⁶26 Voica A ,Oancea C, Tudorache E, Crisan A, Fira-Mladinescu O, Tudorache V, et al. Chronic obstructive pulmonary disease phenotypes and balance impairment. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2016; 11(1):919-925. Disponível em: https://doi.org/10.2147/COPD.S101128 https://doi.org/10.2147/COPD.S101128... ,	2016	A/?	N/I	N/I	N/I	N/I	N/I	N/I	A/-	N/I	A/?
Hellstrom et al.³⁰30 Hellström K, Vahlberg B, Urell C, Emtner M. Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease. Clinical Rehabilitation[Internet]. 2009;23(12):1136–44. Disponível em: https://doi.org/10.1177/0269215509342329 https://doi.org/10.1177/0269215509342329... ,	2009	A/?	N/I	N/I	D/?	N/I	N/I	N/I	D/-	N/I	D/-
Nantsupawat et al.²⁷27 Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207 https://doi.org/10.1177/2150131915577207... ,	2015	A/?	N/I	N/I	N/I	N/I	N/I	N/I	D/-	N/I	D/-
Muti et al.²⁸28 Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752 https://doi.org/10.3390/jcm8101752... ,	2019	A/+	N/I	N/I	N/I	A/ +	N/I	N/I	A/+	N/I	A/+
Roig et al.¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4 https://doi.org/10.1007/s11136-017-1765-... ,	2012	A/-	N/I	N/I	N/I	N/I	N/I	N/I	D/?	N/I	D/?
Porto el al.²⁹29 Porto EF, Pradella CO, Rocco CM, Chueiro M, Jr., Maia RQ, Ganança FF, et al. Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2017;37(2):139–45. Disponível em: https://doi.org/10.1097/HCR.0000000000000246 https://doi.org/10.1097/HCR.000000000000... ,	2017	A/+	N/I	N/I	N/I	A/+	N/I	N/I	A/+	N/I	A/+
Jacome et al.²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391 https://doi.org/10.2522/ptj.20150391... ,	2016	A/+	N/I	N/I	N/I	A/+	A/-	A/+	A/+	N/I	A/-
Park et al.³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609 https://doi.org/10.3390/jcm9020609... ,	2020	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Mkacher et al.³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240 https://doi.org/10.1097/HCR.000000000000... ,	2017	A/+	N/I	N/I	N/I	A/+	A/-	N/I	A/+	N/I	A/-
de Castro et al.³⁹39 de Castro LA, Ribeiro LR, Mesquita R, de Carvalho DR, Felcar JM, Merli MF, et al. Static and Functional Balance in Individuals With COPD: Comparison With Healthy Controls and Differences According to Sex and Disease Severity. Respiratory care [Internet]. 2016;61(11):1488–96. Disponível em: https://doi.org/10.4187/respcare.04749 https://doi.org/10.4187/respcare.04749... ,	2016	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Al Haddad et al.³³33 Al Haddad MA, John M, Hussain S, Bolton CE. Role of the Timed Up and Go Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention[Internet]. 2016;36(1):49–55. Disponível em: https://doi.org/10.1097/hcr.0000000000000143 https://doi.org/10.1097/hcr.000000000000... ,	2016	A/+	N/I	N/I	N/I	A/+	N/I	N/I	A/+	N/I	A/+
Tudorache et al.³⁸38 Tudorache E, Oancea C, Avram C, Fira-Mladinescu O, Petrescu L, Timar B. Balance impairment and systemic inflammation in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2015; 10(1):1847-1852. Disponível em: https://doi.org/10.2147/copd.s89814 https://doi.org/10.2147/copd.s89814... ,	2015	A/-	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/-
Ozalevli et al.²⁵25 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 Clinical and Experimental Research[Internet]. 2011;23(5-6):372–7.Disponível em: https://doi.org/10.1007/bf03325235 https://doi.org/10.1007/bf03325235... ,	2011	A/-	N/I	N/I	N/I	N/I	N/I	N/I	A/-	N/I	A/-
Singh et al.³⁴34 Singh SS, Bhat A, Mohapatra AK, Manu MK, Vaishali K. Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants. Heart & Lung[Internet]. 2019; Disponível em: https://doi.org/10.1016/j.hrtlng.2019.09.006 https://doi.org/10.1016/j.hrtlng.2019.09... ,	2019	A/-	N/I	N/I	N/I	N/I	N/I	N/I	D/-	N/I	D/-
Pereira et al.³⁵35 Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427 https://doi.org/10.1097/HCR.000000000000... ,	2019	A/+	N/I	N/I	A/+	N/I	N/I	A/+	A/+	N/I	A/+
Beauchamp et al.⁸8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311 https://doi.org/10.1177/1479973118820311... ,	2009	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Oliveira et al.²⁴24 Oliveira CC, McGinley J, Lee AL, Irving LB, Denehy L. Fear of falling in people with chronic obstructive pulmonary disease. Respir Med[Internet]. 2015;109(4):483-9. Disponível em: https://doi.org/10.1016/j.rmed.2015.02.003 https://doi.org/10.1016/j.rmed.2015.02.0... ,	2015	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Roig et al.³⁷37 Roig M, Eng JJ, MacIntyre DL, Road JD, FitzGerald JM, Burns J, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respiratory medicine [Internet]. 2011;105(3):461–9. Disponível em: https://doi.org/10.1016/j.rmed.2010.08.015 https://doi.org/10.1016/j.rmed.2010.08.0... ,	2011	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+

Instrument	ICC	Sample	Quality of evidence	Recommendation
BBS	0.82-0.93	106	High	A
BESTest	0.87	46	Low	C
MiniBESTest	0.88	46	Low	C
TUG	0.91-0.95	237	High	A
Brief-BESTTest	0.82	46	Low	C
UST	0.91	60	Moderate	C

Instrument	Administration time	Total cost	Equipment portability	Equipment training	Final score
BBS	2	3	2	2	9
BESTest	1	3	2	2	8
MiniBESTest	2	3	2	2	9
TUG	3	3	2	2	10
Brief-BESTTest	3	3	2	2	10
UST	3	3	2	2	10

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[1] Correspondence Silvia Valderramas svalderramas@uol.com.br

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Balance, falls, and risk of falls in COPD: systematic review of assessment instruments, measurement properties, and clinical utility

Abstract

﻿Objectives

Method

Results

Conclusion

Objectives