Systematic review| Volume 101, ISSUE 9, P1590-1602, September 2020

Balance Impairment and Effectiveness of Exercise Intervention in Chronic Obstructive Pulmonary Disease—A Systematic Review

Published:February 27, 2020DOI:


      • People with chronic obstructive pulmonary disease (COPD) have balance impairment compared to those without COPD.
      • Available evidence shows exercise can improve balance performance in people with COPD.
      • More research on exercise interventions on balance in COPD is needed.



      To systematically review the evidence for balance impairment and effectiveness of interventions on balance in people with chronic obstructive pulmonary disease (COPD).

      Data Sources

      Four electronic databases (Scopus, CINAHL, PubMed, Cochrane Library databases) were searched from inception until June 30, 2019.

      Study Selection

      Two reviewers independently searched with keywords focusing on COPD, postural control, and exercise. Cross-sectional studies related to balance and randomized controlled trials (RCTs) related to the effectiveness of exercise intervention on balance outcomes were included.

      Data Extraction

      Two reviewers independently extracted data of balance impairment on participants, exercise training on balance outcome measures. Methodological quality of cross-sectional studies was assessed using the National Institutes of Health (NIH) Quality Assessment Tool. Methodological quality of RCTs was assessed using the Physiotherapy Evidence Database (PEDro) scale and bias was analyzed using the Cochrane risk of bias.

      Data Synthesis

      A narrative review with descriptive synthesis was used. Fifteen cross-sectional studies and 4 RCTs met the final inclusion criteria. The quality of 10 cross-sectional studies were rated as moderate to high (NIH score≥7). Most studies demonstrated impaired balance in people with COPD than in people without COPD. The quality of all included RCTs was good to excellent (PEDro score=6-9). One RCT had a low risk of bias. Generally, pulmonary rehabilitation program combined with balance training, Tai Chi, and cycling exercise showed significant improvement in balance in people with COPD.


      Impaired balance is evident in people with COPD. Available RCTs suggest that exercise interventions may improve balance performance in COPD patients. However, more research on the effect of exercise interventions on balance in COPD patients is still required.


      List of abbreviations:

      ABC (Activities-specific Balance Confidence), AP (anteroposterior), BBS (Berg Balance Scale), BESTest (Balance Evaluation System test), CoM (center of mass), COPD (chronic obstructive pulmonary disease), NIH (National Institutes of Health), ML (mediolateral), PEDro (Physiotherapy Evidence Database), PR (pulmonary rehabilitation), RCT (randomized controlled trial), SLS (single leg stance), TUG (timed Up and Go)
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        • Global Initiative for Chronic Obstructive Lung Disease
        2020 global strategy for prevention, diagnosis and management of COPD.
        (Available at:)
        • Lopez A.D.
        • Shibuya K.
        • Rao C.
        • et al.
        Chronic obstructive pulmonary disease: current burden and future projections.
        Eur Respir J. 2006; 27: 397-412
        • Patel J.G.
        • Coutinho A.D.
        • Lunacsek O.E.
        • Dalal A.A.
        COPD affects worker productivity and health care costs.
        Int J Chron Obstruct Pulmon Dis. 2018; 13: 2301-2311
        • Miravitlles M.
        • Ribera A.
        Understanding the impact of symptoms on the burden of COPD.
        Respir Res. 2017; 18: 67
        • Elbehairy A.F.
        • Ciavaglia C.E.
        • Webb K.A.
        • et al.
        Pulmonary gas exchange abnormalities in mild chronic obstructive pulmonary disease. Implications for dyspnea and exercise intolerance.
        Am J Respir Crit Care Med. 2015; 191: 1384-1394
        • Alahmari A.D.
        • Kowlessar B.S.
        • Patel A.R.
        • et al.
        Physical activity and exercise capacity in patients with moderate COPD exacerbations.
        Eur Respir J. 2016; 48: 340-349
        • 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 Clin Exp Res. 2011; 23: 372-377
        • Butcher S.J.
        • Meshke J.M.
        • Sheppard M.S.
        Reductions in functional balance, coordination, and mobility measures among patients with stable chronic obstructive pulmonary disease.
        J Cardiopulm Rehabil. 2004; 24: 274-280
        • Beauchamp M.K.
        • Sibley K.M.
        • Lakhani B.
        • et al.
        Impairments in systems underlying control of balance in COPD.
        Chest. 2012; 141: 1496-1503
        • Oliveira C.C.
        • McGinley J.
        • Lee A.L.
        • Irving L.B.
        • Denehy L.
        Fear of falling in people with chronic obstructive pulmonary disease.
        Respir Med. 2015; 109: 483-489
        • Porto E.F.
        • Castro A.A.
        • Schmidt V.G.
        • et al.
        Postural control in chronic obstructive pulmonary disease: a systematic review.
        Int J Chron Obstruct Pulmon Dis. 2015; 10: 1233-1239
        • Mancini M.
        • Horak F.B.
        The relevance of clinical balance assessment tools to differentiate balance deficits.
        Eur J Phys Rehabil Med. 2010; 46: 239-248
        • McCarthy B.
        • Casey D.
        • Devane D.
        • Murphy K.
        • Murphy E.
        • Lacasse Y.
        Pulmonary rehabilitation for chronic obstructive pulmonary disease.
        Cochrane Database Syst Rev. 2015; 2: CD003793
        • Beauchamp M.K.
        • O'Hoski S.
        • Goldstein R.S.
        • Brooks D.
        Effect of pulmonary rehabilitation on balance in persons with chronic obstructive pulmonary disease.
        Arch Phys Med Rehabil. 2010; 91: 1460-1465
        • Beauchamp M.K.
        • Janaudis-Ferreira T.
        • Parreira V.
        • et al.
        A randomized controlled trial of balance training during pulmonary rehabilitation for individuals with COPD.
        Chest. 2013; 144: 1803-1810
        • Mkacher W.
        • Mekki M.
        • Tabka Z.
        • Trabeisi Y.
        Effect of 6 months of balance training during pulmonary rehabilitation in patients with COPD.
        J Cardiopulm Rehabil. 2015; 35: 207-213
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62 (e1-34)
        • NIH National Heart, Lung, and Blood Institute
        Assessing cardiovascular risk: systematic evidence review from the risk assessment work group.
        (Available at:)
        • Maher C.G.
        • Sherrington C.
        • Herbert R.D.
        • Moseley A.M.
        • Elkins M.
        Reliability of the PEDro scale for rating quality of randomized controlled trials.
        Phys Ther. 2003; 83: 713-721
        • Higgins J.P.
        • Green S.
        Cochrane handbook for systematic reviews of interventions.
        (Available at:)
        Date accessed: November 30, 2019
        • Smith M.D.
        • Chang A.T.
        • Seale H.E.
        • Walsh J.R.
        • Hodges P.W.
        Balance is impaired in people with chronic obstructive pulmonary disease.
        Gait Posture. 2010; 31: 456-460
        • Janssens L.
        • Brumagne S.
        • McConnell A.K.
        • et al.
        Proprioceptive changes impair balance control in individuals with chronic obstructive pulmonary disease.
        PLoS One. 2013; 8 (e57949)
        • Janssens L.
        • Brumagne S.
        • McConnell A.K.
        • et al.
        Impaired postural control reduces sit-to-stand-to-sit performance in individuals with chronic obstructive pulmonary disease.
        PLoS One. 2014; 9 (e88247)
        • Crişan A.F.
        • Oancea C.
        • Timar B.
        • Fira-Mladinescu O.
        • Tudorache V.
        Balance impairment in patients with COPD.
        PLoS One. 2015; 10 (e0120573)
        • Tudorache E.
        • Oancea C.
        • Avram C.
        • Fira-Mladinescu O.
        • Petrescu L.
        • Timar B.
        Balance impairment and systemic inflammation in chronic obstructive pulmonary disease.
        Int J Chron Obstruct Pulmon Dis. 2015; 10: 1847-1852
        • De Castro L.A.
        • Ribeiro L.R.
        • Mesquita R.
        • et al.
        Static and functional balance in individuals with COPD: comparison with healthy controls and differences according to sex and disease severity.
        Respir Care. 2016; 61: 1488-1496
        • Iwakura M.
        • Okura K.
        • Shibata K.
        • et al.
        Relationship between balance and physical activity measured by an activity monitor in elderly COPD patients.
        Int J Chron Obstruct Pulmon Dis. 2016; 11: 1505-1514
        • Voica A.S.
        • Oancea C.
        • Tudorache E.
        • et al.
        Chronic obstructive pulmonary disease phenotypes and balance impairment.
        Int J Chron Obstruct Pulmon Dis. 2016; 11: 919-925
        • Rocco C.C.
        • Sampaio L.M.
        • Stirbulov R.
        • Correa J.C.
        Neurophysiological aspects and their relationship to clinical and functional impairment in patients with chronic obstructive pulmonary disease.
        Clinics. 2011; 66: 125-129
        • Boffino C.C.
        • Pereira A.C.
        • Coelho D.B.
        • et al.
        Age and disease have a distinct influence on postural balance of patients with COPD.
        COPD. 2019; 16: 246-253
        • Porto E.F.
        • Pradella C.O.
        • Rocco C.M.
        • et al.
        Comparative postural control in COPD patients and healthy individuals during dynamic and static activities.
        J Cardiopulm Rehabil Prev. 2017; 37: 139-145
        • Mounir K.M.
        • Elserty N.S.
        • Obaya H.E.
        Balance training: its influence on pulmonary rehabilitation.
        Bull Fac Phys Ther. 2019; 24: 8-13
        • Torres-Sanchez I.
        • Valenza M.C.
        • Cabrera-Martos I.
        • Lopez-Torres I.
        • Benitez-Feliponi A.
        • Conde-Valero A.
        Effects of an exercise intervention in frail older patients with chronic obstructive pulmonary disease hospitalized due to an exacerbation: a randomized controlled trial.
        COPD. 2017; 14: 37-42
        • Leung R.W.
        • McKeough Z.J.
        • Peters M.J.
        • Alison J.A.
        Short-form Sun-style t'ai chi as an exercise training modality in people with COPD.
        Eur Respir J. 2013; 41: 1051-1057
        • Muir S.W.
        • Berg K.
        • Chesworth B.
        • Speechley M.
        Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study.
        Phys Ther. 2008; 88: 449-459
        • Lajoie Y.
        • Gallagher S.P.
        Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg Balance Scale and the Activities-specific Balance Confidence (ABC) scale for comparing fallers and non-fallers.
        Arch Gerontol Geriatr. 2004; 38: 11-26