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B-PuRe: Reducing the risk of falls in people with COPD


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.


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 targetted 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.

The project has been funded via a £1.1 million NIHR Advanced Fellowship awarded to Professor Samantha Harrison

Linked publications and other resources

Validity of the Activities-specific Balance Confidence Scale in individuals with chronic obstructive pulmonary disease – PubMed (

Physiotherapy Canada (

Balance Measures Over 12 Months in Individuals With Chronic… : Journal of Cardiopulmonary Rehabilitation and Prevention (

JMIR Research Protocols – Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial

Redirecting (

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 | Full Text (

Book chapter

Pulmonary Rehabilitation | European Respiratory Society (


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.

View some of the cartoon drawings created by public members with COPD who took part in the illustration-based workshops