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Original research
Balance impairment in individuals with COPD: a systematic review with meta-analysis
  1. Kirsti Jane Loughran1,
  2. Greg Atkinson1,
  3. Marla K Beauchamp2,
  4. John Dixon1,
  5. Denis Martin1,
  6. Shaera Rahim2,
  7. Samantha Louise Harrison1
  1. 1 School of Health and Life Sciences, Teesside University, Middlesbrough, UK
  2. 2 School of Rehabilitation Science, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
  1. Correspondence to Kirsti Jane Loughran, School of Health and Life Sciences, Teesside University, Middlesbrough TS13BX, UK; k.loughran{at}


Background People with chronic obstructive pulmonary disease (COPD) are four times more likely to fall than healthy peers, leading to increased morbidity and mortality. Poor balance is a major risk factor for falls. This review aims to quantify the extent of balance impairment in COPD, and establish contributing clinical factors, which at present are sparse.

Methods Five electronic databases were searched, in July 2017 and updated searches were performed in March 2019, for studies comparing balance in COPD with healthy controls. Meta-analyses were conducted on sample mean differences (MD) and reported correlations between balance and clinical factors. Meta-regression was used to quantify the association between mean difference in percentage predicted forced expiratory volume in 1 s (FEV1) and mean balance impairment. Narrative summaries were provided where data were insufficient for meta-analysis.

Results Twenty-three studies were included (n=2751). Meta-analysis indicated COPD patients performed worse than healthy controls on timed up and go (MD=2.77 s, 95% CI 1.46 s to 4.089 s, p=<0.005), single leg stance (MD=−11.75 s, 95% CI −15.12 s to −8.38 s, p=<0.005) and berg balance scale (MD=−6.66, 95% CI −8.95 to −4.37, p=<0.005). The pooled correlation coefficient between balance and reduced quadriceps strength was weak-moderate (r=0.37, 95% CI 0.23 to 0.45, p=<0.005). The relationship between differences in percentage predicted FEV1 and balance were negligible (r2 =<0.04).

Conclusions Compared with healthy controls, people with COPD have a clinically meaningful balance reduction, which may be related to reduced muscle strength, physical activity and exercise capacity. Our findings support a need to expand the focus of pulmonary rehabilitation to include balance assessment and training, and further exploration of balance impairment in COPD.

PROSPERO registration number


  • COPD epidemiology
  • exercise
  • pulmonary rehabilitation

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  • Contributors KL, SLH, MKB, JD and DM contributed to study conception and protocol of the review. KL, SLH, MKB and SR performed the systematic review. KL and GA performed the statistical analysis. KL, SLH, GA, MKB, JD and DM contributed to the interpretation of data. KL drafted the paper and all authors provided critical revisions and contributed to the editing of the paper.

  • Funding The lead author is undertaking doctoral studies funded in association with the Universities Alliance Doctoral Training Alliance for Biosciences. M Beauchamp is supported by an Emerging Research Leaders Award from the Canadian Respiratory Research Network.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request to the corresponding author.