For nine years I have dedicated my research to respiratory rehabilitation, and specifically Chronic Obstructive Pulmonary Disease (COPD). I am interested in the extra-pulmonary (pain and impaired balance) and psychological effects of this lung disease and interventions to complement pulmonary rehabilitation, which is recommended for individuals with COPD.
People with COPD are four times more likely to fall compared to those of a similar age without the disease due to problems with their balance. However, international guidelines for the management of COPD do not include balance training or fall prevention strategies, so there is a gap in the ‘education’ of practitioners tasked with supporting COPD patients and amongst patients themselves who are not being exposed to it.
COPD is a leading cause of morbidity and mortality worldwide and falls in this health population mean significant health and economic consequences. So what are we doing about it? I am currently undertaking a study with colleagues from West Park Health Center in Toronto to determine if a tailored balance exercise programme can reduce the number of falls in people with COPD who are attending pulmonary rehabilitation.
A total of 400 individuals from nine pulmonary rehabilitation centres in the UK, Canada, Portugal and Australia are being recruited to participate in a randomised controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last two years, or recent near fall and who have given consent to be participate in the study, will then be randomly assigned to an intervention or control group.
The intervention group will undergo tailored balance training in addition to pulmonary rehabilitation and receive a personalised home-based balance programme. The control group will receive standard pulmonary rehabilitation and a home programme that does not include balance training. All participants will get monthly calls to provide support and collect healthcare utilisation and loss of productivity data. Both groups will receive home visits at three, six and nine months to ensure proper technique and progression of home exercise programmes.
We will record the number of falls over 12 months using monthly diaries, following completion of their pulmonary rehabilitation, and the patient’s balance control, balance confidence, functional lower body strength, health status and quality of life are being evaluated. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained.
So where do we go next? Well, we expect to complete recruitment (I am the UK lead and working with clinicians at James Cook University Hospital in Middlesbrough to recruit 40 people) in 2019 and our results, which will be available in 2020, will be relevant for guiding clinical and policy-based decision making, given the large population of individuals with COPD and the potential for severe consequences of falls in this population. Findings from this study will also improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. However, we are already thinking about the implication of our work for health care professionals.
My earlier study among health care professionals delivering pulmonary rehabilitation found that they considered the principles and practical application of balance training to be effective, whilst 84% of patients involved enjoyed balance training and reported that it helped them with everyday activities, and 95% indicated their wish to continue with the training. This suggests that we will need tailored strategies to enhance pulmonary rehabilitation. And this could ultimately lead to changes in the current guidelines.
Dr Samantha Harrison is a Reader in Respiratory Rehabilitation in Teesside University’s School of Health and Social Care