This is the first prospective study to demonstrate the validity of the Mini-BESTest in predicting falls in patients with stable COPD. Our findings showed that the Mini-BESTest is an accurate instrument and a good predictor of falls in patients with COPD at 6 and 12 mo. In addition, a higher total score and higher scores on the anticipatory postural adjustment, postural responses, and balance during gait domains of the Mini-BESTest were associated with a lower risk of falling in this patient population.
The Mini-BESTest was used in this study because it evaluates both dynamic balance control and stability during complex gait activities. People with COPD may have a greater risk of falling during dynamic tasks such as walking, those requiring anticipatory postural adjustments or reliance on the musculoskeletal system.7 The Mini-BESTest evaluates anticipatory postural adjustments, reactive postural control, and balance during the gait; therefore, it encompasses the balance components more affected in COPD. In addition, the Mini-BESTest is applicable to clinical practice compared with laboratory-based balance assessment tools. The Mini-BESTest is acceptable for use with older people34 and is able to predict falls in patients with Parkinson's disease.19,20 A recent study showed that several balance tests, such as the BESTest, the Mini-BESTest, the Brief-BESTest, and the Berg Balance Scale (BBS), had acceptable abilities to differentiate patients with and without a history of falls.22 Specifically, the Mini-BESTest was able to identify the retrospective fall status in patients with COPD using a cut-off point of 21.5 (sensitivity of 68% and specificity of 65%).22 Our study showed a Mini-BESTest cut-off point of 22.5, with higher values of sensitivity and specificity (84% and 73.8%, respectively) using a prospective design. In addition, our study evaluated a larger sample (67 vs 46 patients with COPD). Establishing a cut-off for falls prediction is important to identify patients who may require greater attention and specific treatment for postural control impairment.
In this study, a fall prevalence of 37.3% over 12 mo was observed. These findings support previous retrospective35–37 (from 27.8% to 46%) and prospective10,38 (from 31.7% to 40%) investigations in people with COPD. Our study also showed that most patients fell in the first 3 mo after initial balance evaluation and the prevalence of RF increased in the following months. We observed a prevalence of 64% of RF at the 12 mo follow-up, which is in agreement with previous studies (41% and 75%).10,38 Interestingly, the incidence of RF in patients with COPD is comparable to those observed in patients with Parkinson's disease (58.5%).20 Repeated falls may lead to a substantial economic burden on the health system because of multiple visits at the emergency department and hospital admissions39; thus, an earlier identification of the RF in the COPD population is very important.
Better performance on the anticipatory postural adjustment, postural responses, and balance during gait domains of the Mini-BESTest was associated with reduced fall risk. The ability to maintain balance in daily life requires a combination of anticipatory and compensatory postural strategies.41 The anticipatory control reduces the effect of a predictable disturbance, while compensatory control is the only resource of stability for unexpected perturbations.42 A previous study showed that patients with COPD are unable to react quickly in circumstances of postural instability.7 These patients also demonstrated more pronounced deficits in the biomechanics, the anticipatory postural adjustment, and the gait domains of the BESTest compared to age-matched control subjects.7 Furthermore, changes in gait components, such as reduced step length, increased time spent in double support, and worse gait rhythm, are associated with an increased fall risk in COPD.42,43 Our findings confirmed these previous investigations and determined a direct association between anticipatory postural adjustment, postural responses, and balance during gait and a reduced risk of falls. These results suggest that patients with decreased postural response on dynamic balance components can benefit from training to increase stability during postural transitions (eg, sit-to-stand, changes in the base of support) and gait training.
First, we included only clinically stable outpatients; therefore, our findings cannot be generalized to patients on supplemental oxygen, hospitalized patients, or those experiencing an acute exacerbation. Second, we used a clinical instrument for balance assessment that is considered less sensitive and precise for detecting changes in postural balance than laboratory tools.15 However, the Mini-BESTest is less expensive, more accessible in clinical practice and does not require a specialized training prior to administration. Third, the Mini-BESTest evaluates only 4 out of 6 domains from the original BESTest, and other 2 aspects of balance impairment in COPD might have been investigated. However, the Mini-BESTest does not contain redundant items as its full version of the test or have a ceiling/floor effect as balance assessment tools recommended for COPD.15 Of note, the Mini-BESTest takes only 10 to 15 min to administer and has well-documented clinimetric properties in patients with COPD.16,22
This is the first prospective study to demonstrate the good sensitivity and specificity of the Mini-BESTest for predicting falls in clinically stable outpatients with COPD using a cut-off score of 22.5 in the medium- and long-term. The balance impairment in people with COPD contributes to a risk of falling, specifically the impairment in anticipatory postural adjustments, postural responses, and gait.
This work was supported by the São Paulo Research Foundation (FAPESP) (grant #201605968-1 and #2013/20676-9).
2. Agusti A, Soriano JB. COPD
as a systemic disease. COPD
3. Eisner MD, Blanc PD, Yelin EH, et al COPD
as a systemic disease: impact on physical functional limitations. Am J Med. 2008;121(9):789–796.
4. Eisner MD, Iribarren C, Blanc PD, et al Development of disability in chronic obstructive pulmonary disease: beyond lung function. Thorax. 2011;66(2):108–114.
5. Smith MD, Chang AT, Seale HE, Walsh JR, Hodges PW. Balance is impaired in people with chronic obstructive pulmonary disease. Gait Posture. 2010;31(4):456–460.
6. Roig M, Eng JJ, Macintyre DL, Road JD, Reid WD. Postural control is impaired in people with COPD
: an observational study. Physiother Can. 2011;63(4):423–431.
7. Beauchamp MK, Sibley KM, Lakhani B, et al Impairments in systems underlying control of balance in COPD
. Chest. 2012;141(6):1496–1503.
9. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on falls prevention. J Am Geriatr Soc. 2001;49(5):664–672.
10. Oliveira CC, Lee AL, McGinley J, et al Falls by individuals with chronic obstructive pulmonary disease: a preliminary 12-month prospective cohort study. Respirology. 2015;20(7):1096–1101.
11. Bongue B, Dupre C, Beauchet O, Rossat A, Fantino B, Colvez A. A screening tool with five risk factors was developed for fall-risk prediction in community-dwelling elderly. J Clin Epidemiol. 2011;64(10):1152–1160.
12. Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk screening test: a prospective study on predictors for falls in community-dwelling elderly. J Clin Epidemiol. 2001;54(8):837–844.
13. Liao KM, Liang FW, Li CY. Risks of all-cause and site specific fractures among hospitalized patients with COPD
. Medicine (Baltimore). 2016;95(40):e5070.
14. de Luise C, Brimacombe M, Pedersen L, Sorensen HT. Chronic obstructive pulmonary disease and mortality following hip fracture: a population-based cohort study. Eur J Epidemiol. 2008;23(2):115–122.
15. Oliveira CC, Lee A, Granger CL, Miller KJ, Irving LB, Denehy L. Postural control and fear of falling assessment in people with chronic obstructive pulmonary disease: a systematic review of instruments, international classification of functioning, disability and health linkage, and measurement properties. Arch Phys Med Rehabil. 2013;94(9):1784–1799.e7.
16. Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42(4):323–331.
17. Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89(5):484–498.
18. Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35(suppl 2):ii7–ii11.
19. Duncan RP, Leddy AL, Cavanaugh JT, et al Accuracy of fall prediction in Parkinson disease: six month and 12-month prospective analyses. Parkinsons Dis. 2012;2012:237673.
20. Mak MK, Auyeung MM. The mini-BESTest can predict parkinsonian recurrent fallers: a 6-month prospective study. J Rehabil Med. 2013;45(6):565–571.
21. Padgett PK, Jacobs JV, Kasser SL. Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct. Phys Ther. 2012;92(9):1197–1207.
22. 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
. Phys Ther. 2016;96(11):1807–1815.
23. Bestall JC, Paul EA, Garrod R, Garnham R, Jones PW, Wedzicha JA. Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients. Thorax. 1999;54(7):581–586.
24. Kovelis D, Segretti NO, Probst VS, Lareau SC, Brunetto AF, Pitta F. Validation of the Modified Pulmonary Functional Status and Dyspnea questionnaire and the Medical Research Council scale for use in Brazilian patients with chronic obstructive pulmonary disease. J Bras Pneumol. 2008;34(12):1008–1018.
25. Miller MR, Hankinson J, Brusasco V, et al Standardisation of spirometry. Eur Respir J. 2005;26(2):319–338.
26. Pereira CA, Sato T, Rodrigues SC. New reference values for forced spirometry in white adults in Brazil. J Bras Pneumol. 2007;33(4):397–406.
27. King L, Horak F. On the mini-BESTest: scoring and the reporting of total scores. Phys Ther. 2013;93(4):571–575.
28. Maia AC, Rodrigues-de-Paula F, Magalhães LC, Teixeira RL. Cross-cultural adaptation an analysis of the psychometric properties of the Balance Evaluation Systems Test and MiniBestest in the elderly and individuals with Parkinson's disease: application of the Rasch model. Braz J Phys Ther. 2013;17(3):195–217.
29. Lamb SE, Jorstad-Stein EC, Hauer K, Becker C. Development of a common outcome data set for fall injury prevention trials: the Prevention of Falls Network Europe consensus. J Am Geriatr Soc. 2005;53(9):1618–1622.
30. Daniel WW. Biostatistics: A Foundation for Analysis in the Health Sciences. 7th ed. New York: John Wiley & Sons; 1997.
31. Akobeng AK. Understanding diagnostic tests 3: receiver operating characteristic curves. Acta Paediatr. 2007;96(5):644–647.
32. Hosmer DW, Lemeshow S. Applied Logistic Regression. 2nd ed. New York: Wiley; 2000.
33. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. BMJ. 2004;329(7458):168–169.
34. Marques A, Almeida S, Carvalho J, Cruz J, Oliveira A, Jácome C. Reliability, validity, and ability to identify fall status of the Balance Evaluation Systems Test, Mini-Balance Evaluation Systems Test, and Brief-Balance Evaluation Systems Test in older people living in the community. Arch Phys Med Rehabil. 2016;97(12):2166–2173.e1.
35. Beauchamp MK, Hill K, Goldstein RS, Janaudis-Ferreira T, Brooks D. Impairments in balance discriminate fallers from non-fallers in COPD
. Respir Med. 2009;103(12):1885–1891.
36. 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(5/6):372–377.
37. Crisan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD
. PLoS One. 2015;10(3):e0120573.
38. Roig M, Eng JJ, MacIntyre DL, et al Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respir Med. 2011;105(3):461–469.
39. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and non-fatal falls among older adults. Inj Prev. 2006;12(5):290–295.
40. Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther. 2013;93(2):158–167.
41. Maki BE, McIlroy WE. The role of limb movements in maintaining upright stance: the “change-in-support” strategy. Phys Ther. 1997;77(5):488–507.
42. Lahousse L, Verlinden VJ, van der Geest JN, et al Gait patterns in COPD
: the Rotterdam Study. Eur Respir J. 2015;46(1):88–95.
43. Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait characteristics in patients with chronic obstructive pulmonary disease. J Prim Care Community Health. 2015;6(4):222–226.
44. Beauchamp MK, Janaudis-Ferreira T, Parreira V, et al A randomized controlled trial of balance training during pulmonary rehabilitation
for individuals with COPD
. Chest. 2013;144(6):1803–1810.
45. Mkacher W, Mekki M, Tabka Z, Trabelsi Y. Effect of 6 months of balance training during pulmonary rehabilitation
in patients with COPD
. J Cardiopulm Rehabil Prev. 2015;35(3):207–213.