B-PuRe: Reducing the risk of falls in people with COPD
Projects
IMAGE: Cartoon drawing by public participant, illustrating her lived experience of COPD
Balance training delivered alongside Pulmonary Rehabilitation to reduce falls risk for people with Chronic Obstructive Pulmonary Disease (B-PuRe)
This £1.1 million NIHR-funded research project will explore why people with COPD are more likely to fall – and if balance training could help to reduce this.
Summary
More than 1.2 million people in the UK are diagnosed with COPD, which causes breathlessness, coughing and frequent chest infections. Those with COPD are four times more likely to fall than healthy adults of the same age due to poor balance. Higher levels of socio-economic deprivation are also linked to a greater risk of falling. Pulmonary rehabilitation currently includes exercise and disease education, but not balance training.
Working with NHS trusts across the Durham and Tees Valley Alliance, as well as with academics from Newcastle, Northumbria and Manchester Metropolitan Universities, Professor Samantha Harrison from Teesside University will investigate the factors that contribute to the increased risk of falls and look at ways to mitigate them.
The team will also develop personalised balance training, taking into account physical, psychological and social factors, and incorporate it into pulmonary rehabilitation for people with COPD.
Project background
COPD patients are breathless and often live in the poorest communities. They are more likely to fall than healthy adults of the same age because their balance is worse. As we age muscles become weaker and slower to react to unsteadiness.
Symptoms and inactivity mean this happens quicker in people with COPD. Physical changes are only one reason people fall, social and environmental factors are also important. For example, people caring for grandchildren, because childcare is not affordable, and living in small houses are more likely to fall over toys.
Pulmonary rehabilitation is usual treatment for COPD, including 6-8 weeks of exercise and disease education, to reduce breathlessness. Balance training is not included but is needed to reduce falls risk.
Professor Samantha Harrison from Teesside University is leading the UK part of an international research study testing if pulmonary rehabilitation with balance training reduces falls.
Recruitment is now complete and analysis underway, and the research raises interesting questions:
- Can balance training be personalised?
Balance training can be improved if it meets the physical needs of people with COPD. Discussions with other international investigators indicate that people recruited in Middlesbrough (an area with high levels of people living in poverty) fall eight times more than those from other countries. This may be due to social and environmental situations that we need to understand better.
- Can we encourage attendance?
Only 42% of people with COPD complete pulmonary rehabilitation.
- Can balance training be continued at home?
Most benefits of exercise disappear after 12 weeks if discontinued.
Project aims
- Personalise pulmonary rehabilitation with balance training for people with COPD
- Encourage attendance
- Fit balance training into patients’ everyday lives
Design and methods
Stage 1
Behavioural component: Review research to identify what aspects of exercise training improve balance in people with COPD.
Physical component: Investigate if poor balance is due to weaker muscles and slower reactions by comparing associations in 20 people with COPD to 20 healthy older adults.
Psychosocial component: Observe 10 people with COPD (and carers) in their homes and have discussions to understand their experience of living with COPD.
Stage 2
Draw together findings from stage 1 to develop balance training for people with COPD and a training package for clinicians to deliver it. Stakeholders, clinicians, patients and carers can all play a role in helping to improve balance training.
Stage 3
Forty people with COPD will receive pulmonary rehabilitation with or without balance training consisting of twice weekly sessions at hospital and one at home, followed by a six-month supported home programme. Monthly phone calls will enquire about falls and home exercise/balance training. Balance and muscle testing will take place before and after pulmonary rehabilitation and 6-months later.
Prof Harrison will also observe and interview eight people with COPD receiving balance training in their homes, sometimes with their carers, at these time-points, to uncover what support is needed to continue balance training. She will assess if balance training was delivered as intended and the cost of delivery. This information will inform a future trial.
Patient and public involvement
Six patients enrolled in pulmonary rehabilitation, seven Breathe Easy support group members and a PPI consumer panel supported the development of the research programme. Three meetings a year will be held with 10-20 Breathe Easy members and the research team will include two patients.
Sharing the findings
Prof Harrison will deliver pulmonary rehabilitation roadshows, based on the clinician-training package, to patients, carers and clinicians from targeted communities. One show will be video-recorded for use online. People from creative arts and games industries will help develop exciting ways to share the results with the public. Findings will also be published in scientific journals.
Findings from Stage 1 – Psychosocial component
Living with COPD in the real world
The researchers spent time with people who have COPD, in their homes. Their observations, coupled with interviews and input from PPI members has led to the co-development of an infographic (below) which illustrates the complex challenges faced by people living with COPD, on a day to day basis.
Findings from Stage 1 – Behavioural component
We wanted to find out whether there was any evidence that exercise-based interventions could help improve balance and reduce falls in people with COPD.
We also wanted to know what the ‘key ingredients’ were in those interventions found to be beneficial.
To do this, we conducted a systematic review and meta-analysis. A systematic review and meta-analysis tries to find and compare all of the existing research on a particular topic.
We analysed 34 good-quality studies which included a total of 1712 participants.
We found only weak evidence that exercise for people with COPD improves balance and we do not know if this improvement leads to fewer falls.
We also found that when balance training is included as part of pulmonary rehabilitation it seems to be more beneficial than other forms of exercise.
You can read a plain language summary of the review, here.
You can view a storyboard of the review findings, here.
You can read the full paper (published June 2024) here: Exercise-based interventions targeting balance and falls in people with COPD: a systematic review and meta-analysis | European Respiratory Society (ersjournals.com) – published June 2024
Developing an innovative patient and public involvement and engagement approach for people with chronic breathlessness.
At the start of this project, the research team organised comic-based illustration workshops with patients with COPD, to support the building of meaningful relationships with this group, and to offer an innovative patient and public involvement and engagement approach for people with chronic breathlessness.
Talking about breathlessness can be emotionally challenging. People can feel a sense of illegitimacy and discomfort in some research contexts. Comic-based illustration (cartooning) offers an opportunity to communicate in a more creative and inclusive way.
Cartooning was used with members of Breathe Easy Darlington, a support group for people with breathlessness, as a way of helping the research team understand how breathlessness impacts daily lives.
Five 90-min cartooning workshops were delivered online and involved 5–10 Breathe Easy members per session. The sessions were led by a professional cartoonist whilst the research team facilitated discussions about breathlessness and related issues.
The experience of living with breathlessness was illustrated via cartoon characters and ideas were explored through conversations about the illustrations. People found cartooning fun and sharing the experience with the research team helped them to become part of an existing group who will support a long-term research project directly impacting research investigating balance in people with lung disease.
The Breathe Easy members were able to tell their stories via illustrations allowing the research team an insight into different aspects of living with breathlessness. The illustrations showed characters leaning against trees and chairs, sweating and sitting down. The need for physical support caused embarrassment, while people struggled to appear “normal”.
Conversations about the illustrations revealed that the idea of “balance” aligns with a loss of control, disorientation, and unsteadiness which causes intense fear and shame.
The active participation of researchers in the workshops and other activities helped to foster trusting relationships.
We published an article in BMC Research Involvement and Engagement (March 2023) to share the findings from our work delivering these workshops.
Linked publications and other resources
Physiotherapy Canada (utpjournals.press)
https://doi.org/10.1136/thoraxjnl-2019-213608
Book chapter
Pulmonary Rehabilitation | European Respiratory Society (ersjournals.com)
Media
Physio matters podcast (1) Facebook Live | Facebook
Case study: Using comic-based art as an innovative patient and public involvement approach in people with chronic breathlessness
The COVID-19 pandemic has cast a light on health inequalities emphasising the importance of finding innovative ways to include marginalised groups in research. Involving people with chronic breathlessness in research activities is challenging, but comic-based illustration offers an innovative and creative opportunity to communicate in a different way that is more inclusive. This is important because increasing the diversity of the people involved in research likely increases the involvement of those who the research affects leading to greater impact.
Drawings have been used in other populations (asthma, post-myocardial infarction and chronic pain) to draw out insightful knowledge about the illness experience and comic-scripts are a popular tool used in health communication. However, as far as we know, it has not been applied as a PPI activity in people with chronic breathlessness.
The research team delivered six, 90-minute online comic-based illustration workshops to members of Breathe Easy, Darlington (UK). The workshops were facilitated by a professional cartoonist and three researchers were active participants.
The approach prompted the research team to reassess their assumptions about ‘balance’ and what it means to people with breathlessness. The illustrations highlighted how breathlessness leads to an overwhelming sense of disorientation and loss of control that makes people feel unsteady.
This activity also led to the development of a project logo that the PPI members produced.
Drawing comics is a fun and nostalgic activity that helped to foster trusting relationships and could be applied as a useful research method in future.
Members of the Breathe Easy Darlington group were participants in the cartoon workshop and are PPI members on the project. Find out more about Breathe Easy Darlington.
You can view and download some of the cartoon drawings, below.