Evaluation of Balance, Walking Speed, Quadriceps Femoris Muscle Strength and Quality of Life in Individuals with COPD with and Without Falls

  

    

    
Group
    

    

  
  

    
Falling(n:34)
    
Non Falling(n:40)
    

    

  
  

    
Avarage±

      SS
    
Middle

      (min. - maks.)
    
Avarage ±

      SS
    
Middle

      (min. - maks.)
    
p*
    

  
  

    
SMMT
    
26.07 ±    1.82
    
26 (24-30)
    
26.41 ±    2.28
    
26 (24-30)
    
0.702
  
  

    
BERG Balance

      Test
    
25.47 ±    10.26
    
21 (14-53)
    
43.14 ±    9.2
    
45 (18-56)
    
<0.001
  
  

    
2 Min. Walks

      Test
    
66.27 ±    18.29
    
64.5    (20-100)
    
84.61 ±    37.63
    
78.5    (20-210)
    
0.024
  
  

    
QF Muscle Strength Left
    
37.61 ±    9.36
    
39.6    (22.4-61)
    
46.39 ±    12.69
    
43.45    (22.53-74.7)
    
0.003
  
  

    
Tinetti Falling    Activity Scale
    
72.17 ±    10.61
    
74 (30-    85)
    
52.55 ±    19.98
    
56    (15-100)
    
<0.001
  
  

    
SGRQ Symptom
    
88.16 ±    7.97
    
90.42    (61.16-97.8)
    
80.66 ±    14.27
    
83.93    (44.94-100)
    
0.027
  
  

    
SGRQ Total
    
83.25 ±    12.67
    
85.93    (42.79-98.16)
    
74.21 ±    16.27
    
75.28    (21.28-97.92)
    
0.011
  
  

    
Fatigue
    
4.34 ±    0.84
    
4.45    (1.3-7)
    
3.77 ±    1.01
    
4.15    (1.3-4.6)
    
0.006
  
  

    
*Mann Whitney U    test, s.deviation: standard deviation, min: minimum, max: maximum, n: number    of individuals, SGRQ: Saint George Respiratory Questionnaire; 2MWT: 2-min    Walking Test; SMMT: Standardised Mini Mental Test 
  

Table 4: Comparison of SMMT scores, Berg balance test, 2 MWT, QF muscle
strength, Tinetti Falling Activity Scala, SGRQ and fatigue of individuals with
COPD with and without falls.

Discussion

In this study, we aimed to evaluate balance, walking speed, QF muscle strength, quality of life and fatigue in individuals with COPD with and without falls. As a result of our study, it was observed that there was no difference between the pain severity, FEV1, FVC, FEV1/ FVC, PEF and BMI variables according to the groups. There was also no difference between MRC dyspnoea scores according to the groups. Accordingly, it can be said that MMRC, FEV1, FVC, FEV1/FVC, PEF, BMI have no significant effect on the history of falls in individuals with COPD. BERG balance test and 2 min walk test scores of the fall group were lower than the non-fall group. According to the groups, Tinetti fall effectiveness scale scores were higher in the falling group than in the non-falling group. Right and left QF muscle strength values were found to be lower in the falling group. According to the groups, SGRQ activity score of the falling group was found to be higher. As a result, individuals with COPD who fell were found to have higher fall risk, higher fatigue values, weaker QF muscle strength, lower balance performance and walking speed than non-falling individuals. As a result of our study, balance, walking speed, QF muscle strength, quality of life and fatigue levels were found to be low in individuals who fell and all our hypotheses were supported.

Respiratory Functions

The perception of COPD as an intermittent, progressive disease characterized by increased levels of symptoms associated with deteriorating lung function and limited variability in symptom presentation was distorted by the increasing evidence base and better understanding of the disease. Beyond the weak correlation now detected between symptom detection and hard exhalation volume (FEV1) in 1 second, it is now believed that COPD symptoms show high seasonal, weekly and daily variability [30].

A five-year SFT follow-up of 1888 healthy, asymptomatic men aged 35-74 showed that smokers who continued smoking had a faster FEV1 decline than non-smokers, while those who quit smoked had a decrease in Fev1. Quitting smoking benefits women more than men. A study in the United States and Canada that followed 3,348 men aged 35-60 and 1998 women for 5 years showed that women who quit smoking had a greater increase in FEV1 than men [31].

In a study conducted by Yenilmez and Ark (2018) with individuals with COPD, as the severity of dyspnea increases, social participation, self-determination, physical, homework and religious activities are to be affected and significantly decreased. The study also found that individuals who did not participate in social activities were more likely to experience severe dyspnea than those who participated. It is believed that the increased severity of dyspnea may be due to increased symptom burden in individuals with increased levels of adverse effects of the disease, and that participation in social activities may be reduced as a result of increased sensitivity to dyspnoe severity [32]. In his first and last study, he showed that the perceived level of shortness of breath experienced during GYA was higher in those who did not fall [33].

The current study found no distinction between the variables FEV1, FVC, FEV1/FVC and PEF by group. Furthermore, no significant difference was found between MMRC dyspnea scores by group. Because the prognosis of COPD is determined by the degree of respiratory obstruction, we believe that respiratory functions will decrease as a result of factors that cause COPD, such as increased age, smoking and genetic factors.

Balance

Individuals with COPD are well-known for respiratory dysfunction, as well as muscle function disorders, reduced exercise capacity, and imbalance disturbances. Recently, the prevention of falls has gained great importance due to increased evidence of imbalance in this population and increased fall rates [34]. According to his study, hypoxemia, dyspnea and fatigue are factors associated with diseases related to imbalance and falls in people with COPD [35]. Studies have shown that in individuals with COPD, there are probably multiple systemic symptoms of the disease plus age-related loss of balance, which potentially increases the risk of falling down and a disturbance of body balance that enhances the consequences [36]. Individuals with COPD have been found to have worse functional balance and static balance scores compared to the healthy control group [4].

Aymir et al. carried out a study involving 24 healthy individuals, age-matched with 24 individuals with moderate to severe COPD, and found that imbalance in the patient group was significantly associated with extrapulmonary conditions such as physical activity levels, exercise capacity, muscle strength in the lower limbs and a history of falls [37]. In another study, individuals with COPD had a higher incidence of imbalance and falls [38]. Tudorache et al., in a study of 41 COPD individuals and 20 healthy individuals with no significant differences in anthropometric data, associated advanced and acute COPD with an increased history of falls, systemic inflammation, imbalance and lower extremity muscle weakness [39].

In a sample of individuals with COPD and healthy counterparts, a prospective analysis was conducted over the first 12 months of the study to examine the formation of falls and associated risk factors. Participants were categorized into non-falling and falling groups. The findings indicated that loss of balance was the most common cause of falls. Notably, individuals with COPD exhibited a higher prevalence and incidence rate of falls compared to the general older adult population. This highlights the heightened risk of falls in this demographic, underscoring the need for targeted interventions to improve balance and reduce fall risk in patients with COPD [40].

In the study by Oliveira et al., the fear of falling was assessed using the Falls Efficacy Scale-International (FES-I) among 40 individuals with COPD and 25 age- and gender-matched controls. The evaluation of physical function included measurements with a quadriseptic hand dynamometer, the Berg Balance Scale, and the Six-Minute Walking Test. The results indicated that a heightened fear of falling correlated with decreased quadriseptic strength and impaired balance [41].

In the current study, it was observed that individuals with COPD who experienced falls had significantly lower scores on the Berg Balance Test.

Additionally, these falling individuals exhibited poorer balance performance and slower walking speeds. These findings underscore the importance of not only addressing common COPD symptoms such as dyspnea, cough, and sputum production but also evaluating and improving balance in this population. Incorporating balance training and walking exercises into the exercise regimens of individuals with COPD could be vital in reducing their risk of falls and enhancing overall safety and mobility.

Walking Speed

Walking speed serves as a crucial indicator of exercise capacity (6MWT) rather than merely daily physical activity in individuals with COPD. Utilizing the 6-minute walking test (6MWT), recognized as the predominant field test for assessing exercise capacity in cardiopulmonary diseases, researchers examined factors influencing walking speed in a cohort of 130 stable COPD patients using two walking speed protocols (normal maximum and tempo). The findings indicated that while walking speed was independently associated with 6MWT, it did not correlate with daily physical activity levels [42].

Exercise intolerance is a predominant symptom in COPD patients. In a study by Sanseverino et al., involving 22 subjects (11 with COPD, FEV1 = 45 ± 17% of predicted, and 11 matched healthy individuals), the researchers aimed to compare transportation costs and walking variability at different speeds. The results suggested that interventions targeted at alleviating shortness of breath and modifying walking patterns could enhance patients' self-selected walking speeds and improve their quality of life [43]. Further investigation involving 511 individuals with varying degrees of COPD severity (mild to very severe) compared to 113 healthy controls demonstrated that COPD patients exhibited significantly lower walking speeds during the 6-minute walking test [44]. Notably, individuals with COPD who experienced falls displayed even lower walking speeds. This decrease in quadriceps (QF) strength among COPD patients might be attributed to compounded factors such as muscle weakness, balance impairments, and the development of fear surrounding falling, all of which can lead to physical inactivity and adversely affect walking speed.

In patients with chronic lung conditions, a combination of respiratory symptoms, reduced physical activity, muscle weakness, and impaired coordination can result in balance issues and an increased risk of falls. These falls can lead to serious health complications and impose a substantial financial burden on healthcare systems globally. Therefore, it is essential to conduct thorough evaluations of individuals with chronic respiratory diseases for balance issues, fall risks, muscle strength, and the implementation of adequate pulmonary rehabilitation programs.

The management of COPD should extend beyond improving lung function and preventing exacerbations to include addressing comorbidities, promoting physical activity, and supporting smoking cessation. This holistic approach aims to enhance the quality of life for individuals with COPD. We advocate for comprehensive assessments of balance, walking speed, QF muscle strength, and quality of life, followed by tailored rehabilitation programs.

Our findings will serve as a valuable resource for future research aimed at understanding falls in COPD patients. While most studies have categorized participants into COPD and healthy groups, our research diverges by focusing on the distinctions between falling and non-falling individuals within the COPD population. Our findings indicate that factors such as muscle strength loss, balance issues, low walking speed, and fatigue are significant contributors to fall risk in patients with COPD, ultimately impacting their quality of life.

Quadriceps Femoris Muscle Strength

In both acute and chronic diseases, the degradation of muscle proteins leads to a decrease in muscle mass. In the case of chronic diseases like Chronic Obstructive Pulmonary Disease (COPD), this muscle loss occurs gradually, resulting in atrophy of skeletal muscles. Such atrophy adversely affects respiratory function and exercise tolerance, which in turn deteriorates the quality of life for affected individuals. The gradual loss of muscle mass contributes to a cycle of physical inactivity and further muscle deterioration, exacerbating respiratory symptoms and leading to increased shortness of breath. This decline in physical capabilities can create a sense of dependency and reduce patients' overall engagement in daily activities. As muscle strength diminishes, the risk of falls and associated complications rises, further contributing to morbidity. Moreover, the impact of muscle loss in COPD is not merely physical; it has significant implications for mental health and overall well-being. Patients may experience feelings of frustration, sadness, or anxiety related to their declining health, which can further hinder their motivation to participate in rehabilitation and engage in physical activity [45].

Over time, the cumulative effects of muscle atrophy, reduced exercise tolerance, and diminished respiratory function can lead to a higher risk of mortality among COPD patients. Therefore, it is crucial for healthcare providers to address muscle mass preservation and enhance physical activity through tailored rehabilitation programs, nutritional support, and interventions aimed at improving overall muscle strength and endurance. By focusing on these factors, we can potentially improve the quality of life and longevity for individuals living with COPD and other chronic diseases. [45].

In a thesis study that investigated the severity of the disease and the ability to exercise of QF strength, balance and knee joint proprioseption in individuals with COPD, Saritaj found that 82 individuals with stable COPD between the ages of 40 and 80 and 21 healthy adults included in the study, and compared to healthy individuals, some people with COPD had reduced exercise capacity in parallel with severity. According to the results of the control group, the loss of strength in the muscles that operate the knee joint was statistically significant in the patient groups and compared between the groups and there was a positive meaningful relationship between the exercise capacity of our patients and the muscle strength loss [46].

To measure the role of peripheral muscle strength, in 41 patients with consecutive COPD (FEV1, 43 +/- %19) Weak 6 MWD (372 +/) in a study that re-examined the potential determinants of exercise capacity (6 minutes walking distance [6 MWD] and maximum oxygen consumption [V02max])/- 136 m) and VO2max (1.35 +/- 0.60 L, 71%), decreased respiratory and peripheral muscle strength (QF 74 +/-27) were found. It was concluded that lung function and peripheral muscle strength in COPD are important determinants of exercise capacity [47]. Gosselink et al. included 22 healthy elderly individuals and 40 healthy COPD patients with the aim of determining the degree of respiratory and peripheral muscle weakness in individuals with moderate to severe chronic obstructive pulmonary disease (COPD). Compared with normal patients, respiratory muscle strength (average 64% of control subjects' value [% control] and peripheral muscle strength (average 75% control) were found to decrease [48].

49-year-old women participated in the study by Borges et al. Fall records, fall- related self-sufficiency (FES-I Brazil), functional abilities (Temporary Staircase Ascension and Bounce Test [TUDS] and Temporary Up and Walk Test (TUG]), muscle strength of the lower limbs (bone extenders and ankle planar flexors) were evaluated. Older women with fall records over the past year have found lower strength in the knee extender and plantar flexor muscles. Those with lower self-sufficiency associated with falling have found lower power of the knee extenders [49].

As a result, in the current study, the right and left QF muscle forces of the individuals with COPD were weaker than those of the individuals with COPD who did not fall. Well-known risk factors for falls in individuals with COPD include advanced age, increased comorbidities, dyspnea, physical inactivity, muscle weakness, fear and decreased balance confidence in lower extremity muscle weakness, as well as functional deficiencies, etc, it has been reported that there is a lack of performance and postural control [11]. We think that the presence of lower QF muscle strength in individuals with falling COPD increases the number of falls. We think that studies involving balance assessment and treatment should be performed in COPD individuals as balance loss may occur, which is one of the important determinants of mortality in individuals with COPD, due to decreases in muscle strength, physical activity and exercise capacity in COPD individuals.

Fatigue

Individuals with chronic obstructive pulmonary disease and asthma are often reported up to dyspnea in fatigue. Approximately 43-58% of patients diagnosed with COPD experiencing fatigue. The person minimizes the effort spent during the day to minimize shortness of breath and fatigue. In this case, the day-to-day life activities are limited and often the person becomes dependent on someone else. As fatigue progresses, it is defined as "energy shortage" and the quality of life is negatively affected. Fatigue is a significant symptom that requires evaluation and treatment in individuals with COPD [50].

In his study, Paddison et al. aimed to examine the intensity of fatigue in COPD patients by comparing them with levels, and as a result, a significant relationship was found between fatigue and COPD severity. Also, reports of fatigue suggested that it predicts the risk of future hospitalization [47].

Pana et al. fell rate with personally reported or perceived fatigue in older adults (=60 years), which has done recurrent falls, in a systemic review that reports the findings of studies investigating the association between fall injuries or the risk of falls, most of the studies concluded that they provide strong evidence of the association between increased fall rate or risk of falls and fatigue in older adults [51].

Renner et al. recently conducted the study between the ages of 64- 100 and 5642 men, which aimed to evaluate the relationship between fatigue and the risk of a forward fall (%Men with 26) were found to be older, 24% less active and had worse physical performance [52].

As a result of the current study, fatigue severity of COPD individuals who fell similarly to the literature was found to be higher. Fatigue is an important symptom in individuals with COPD. However, in people with COPD who fall frequently, balance and muscle strength loss, fatigue affects individuals even more negatively. We believe that fatigue severity can negatively affect the treatment process and motivation of these individuals. For this reason, we think that it is important to develop the necessary strategies for the assessment and prevention of fatigue in COPD individuals.

Quality of Life

The factors that may be associated with quality of life impairment are not fully understood. But in most of the studies, it has been shown that dyspnea is the most important factor that has been shown to impair quality of life in COPD. In addition, various factors such as body mass index, age, six-minute walking distance have been associated with poor quality of life in COPD [53].

Improving the quality of life in COPD is more important than prolonging life. Sensitive and realistic determination of quality of life can be achieved by correct perception of conceptual differences [54]. Miravitlles et al. 68,2 and FEV1(%) of the average age of 49,2% of COPD individuals with an average age of 222 aimed to study the factors that determine quality of life. As a result of the study, they found that in individuals with COPD, quality of life showed significant impairment; chronic cough and dyspnea were associated with a higher quality of life. Strategies aimed at changing these factors have concluded that they will significantly improve the well-being of individuals with COPD [55]. Budapest National Koranyi Institute of Chest Diseases 2019-2020'de COPD diagnosing individuals with 321 COPD of frequent flare-ups in a survey-based cross-sectional study combined with clinical data aimed at identifying the most important risk factors affecting quality of life among individuals with COPD, they found that multiple comorbidities and tobacco smoking were associated with poorer quality of life [56].

In a study aimed at assessing the relationship between healthrelated quality of life (HRQL) and disease severity using lung function measurements, 168 COPD individuals were included and the quality of life in COPD was associated with disease severity and age they have found that it is getting worse [57]. When the literature was examined, the study investigating the quality of life of COPD subjects who fell and did not fall was not found and therefore the results of the studies related to factors affecting quality of life in elderly individuals and COPD subjects who did not fall and fall in this section were reported. In our study, the quality of life in COPD individuals who fell was found to be lower than in the group that did not fall. The presence of COPData symptoms and the addition of falls in addition to this condition, together with the result of complications, make the quality of life worse. Therefore, as a result of rehabilitation programs that reduce symptoms in COPD subjects, we think that dyspnea, exercise capacity, walking distance, oxygen use and hospitalization will decrease and the quality of life will improve significantly.

Limitations of the Study

The COPD individuals included in the study were included from only one institution. Forward studies, instead of falling and non-falling groups, groups can be created according to the frequency of falls or a study can be planned with groups consisting of falling, non-falling and healthy individuals. We also recommend that the population be increased and diversified in future studies.

Author Statements

Funding Statement

No external funding was received for this study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CrediT Authorship Contribution Statement

All authors approve the final version of the manuscript, including the authorship list and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors have read and approved the final version of the manuscript for submission.

YK: Conceptualization, Data curation, Formal Analysis, Writing, original draft

MS: Conceptualization, Data curation, Formal analysis, Writing, original draft

SD: Conceptualization, Data curation

Data Availability

Data will be made available on request. The data that has been used is confidential.

References

1. Saadet SA, Çevik K. Advanced exercises are applied to affect fatigue and quality of life. Zukurova Medical Journal. 2020; 45: 662-671.
2. Keskin T, Baskurt Z. Pulmonary rehabilitation in elderly individuals diagnosed with coagulation. Journal of the Institute of Health Sciences of Celal Bayar University. 2021; 8: 157-161.
3. Kara A. The impact of the perception of the disease on the quality of life in individuals with COPD. Master’s thesis. Fisheries University Institute of Health Sciences. 2019.
4. Stone M. Effects of creative dance-based exercise training on respiratory, balance and cognitive functions, respiratory and peripheral muscle strength and functional capacity in patients with chronic obstructive pulmonary disease (COPD). Doctoral thesis. Bezmialem Foundation University Institute of Health Sciences, Istanbul. 2022.
5. Nalan OGAN, Uzunkulaoglu A, Akpinar EE. Effects on the balance of severity in patients with chronic obstructive lung disease. Effect of diarrhea on balance in patients with chronic obstructive lung disease. Bosok Medical Journal. 2020; 10: 94-99.
6. Ulusoy S. Impact of the level of vulnerability on balance, cognition and dayto- day life activities. Master’s thesis. Hacettepe University, Institute of Health Sciences, Ankara. 2020
7. Crisan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. An imbalance disorder in COPD patients. PloS a. 2015; 10: e0120573.
8. Unbeaten O, Gürsoy S, Evyapan F, Kitis A. Study of activity killer and quality of life for individuals with COPD. Journal of Research on Ageing Problems. 2018; 11: 30-36.
9. Arslan C, ünsar S. Effects on the balance of dyspnea severity in chronic obstructive pulmonary patients. Anadolu Journal of Nursing and Health Sciences. 2021; 24: 42-50.
10. Jácome C, Cruz J, Oliveira A, Marques A. Validity, reliability and ability to determine the falling state of the Berg Balance Scale, BESTest, Mini-BESTest and briefly BEST in COPD patients. Physical therapy. 2016; 96: 1807-1815.
11. First T, Short EP, Current B, Koran Lion G, Kyyan E. The investigation of falls and balance from the perspective of activities of daily living in patients with COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease. 2021; 18: 147-156.
12. Roig M, Eng JJ, MacIntyre DL, Road JD, FitzGerald JM, Burns J, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respiratory medicine. 2011; 105: 461- 469.
13. Oliveira CC, Annoni R, Lee AL, McGinley J, Irving LB, Denehy L. Falls prevalence and risk factors in people with chronic obstructive pulmonary disease: a systematic review. Respiratory Medicine. 2021; 176: 106284.
14. GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease 2021 Report.
15. The MRC breathlessness scale. Stenton, C. Occupational medicine. 2008; 58: 226-7.
16. Güngen C, Ertan T, Eker E, Vivar R, Engin F. The standardized mini-mental test in the Turkish society is valid and reliable. Turkish Psychiatric Journal. 2002; 13: 273-281.
17. Broche-Pérez Y. Alternative tools for the adult mayor’s cognitive exploration: The entire Minimental Test. Revista Cubana de Medicina General Integral. 2017; 33: 251-265.
18. Shahin F, Bukhari R, Right S, East B, Koran B. Validity and reliability of the English version of the Berg Balance Scale in patients. Journal of Physical Medicine & Rehabilitation Sciences. 2013; 16.
19. Self-control B. Evaluation of the effects of phase I, phase II cardiac rehabilitation and nmes use on functional capacity in early-term patients after coronary artery bypass transplant surgery with myocardial tissue dopplers and a two-minute walking test. 2019.
20. Washburn RA, McAuley E, Katula J, Mihalko SL, Boileau RA. The physical activity scale for the elderly (PASE): evidence for validity. J Clin Epidemiol. 1999; 52: 643-51.
21. Wang Z, Rong Y, Gu L, Yang Y, Du X, Zhou M. Reliability and validity of a fall risk self-assessment scale for elderly people living in communities in China: a pilot study. BMC Geriatrics. 2022; 22: 272.
22. Brinkrnann JR. A hand-held and constant dynamometer comparison for measuring the strength of patients with neuromuscular disorders. Journal of Orthopaedic & Sports Physical Therapy. 1994; 19: 100-4.
23. Sertel M, Shimsek T, Yümin E, Aras B. Assessment of the validity and reliability of the Turkish version of the self-assessed fall risk survey in older individuals. Physiotherapy Quartly. 2020; 28: 50-55.
24. Cut In, Current M. Do Quadriceps and Hamstring Muscle Strength Affect Dynamic Balance Performance? Turkish Journal of Sports Sciences. 2020; 3: 1-7.
25. Miodonska Z, Stepien P, Badura P, Choroba B, Kawa J, Derejczyk J, et al. Inverse data-based walking criteria based on the Tinetti Test and Berg Balance Scale assessments. Biomedical Signal Processing and Control. 2018; 44: 38-47.
26. Adile AY, CIRAY N. Activity level and quality of life of patients with chronic obstructive pulmonary disease. Nine September University School of Nursing Electronic Journal. 2023; 16: 39-50.
27. Polatli M, Yorgancioglu A, Aydemir ö, Demirci NY, Kirkil G, Nayci SA, et al. The validity and reliability of the St. George Respiratory Survey. Tuberk Toraks. 2013; 61: 81-87.
28. Threesome FD, Iron AK, Polat G, Strong SZ. Smoking Characteristics of COVID-19 Facts. Izmir Breast Hospital Journal. 2004; 18: 107-112.
29. Armutlu K, Korkmaz NC, Keser I, Sumbuloglu V, Akbiyik DI, Guney Z, et al. Validity and reliability of the Fatigue Violence Measurement in Turkish patients with multiple sclerosis. International Journal of Rehabilitation Research International Zeitschrift fur Rehabilitationsforschung Revue internationale de recherches de réadaptation. 2007; 30: 81-5.
30. Miravitlles M, Ribera A. Understanding the effects of symptoms on the burden of COPD. Respiratory Research. 2017; 18: 67.
31. Subdued B, Born N. Determination of Dispne, Social Support and Quality of Life for Individuals with COPD. Journal of Research Development in Nursing. 2023; 25: 1-22.
32. Chuatrakoon B, Uthaikhup S, Ngai SP, Liwsrisakun C, Pothirat C, Sungkarat S. Effectiveness of home-based balance and lung rehabilitation programmes in people with chronic obstructive lung disease: a randomized controlled study. Eur J Phys Rehabilitation Med. 2022; 58: 478-486.
33. First T, Short EP, Flowers B, Koran Lion G, Kyyan E. Study of decrease and balance in patients with COPD from the perspective of daily life activities. COPD: Journal of Chronic Obstructive Lung Disease. 2021; 18: 147–156.
34. Ozalevli S, Ilgin D, Narin S, Akkoclu A. The relationship between diseaserelated factors and balance and decreases among elderly people with COPD: a cross-study. Aging Clin Exp Res. 2011; 23: 372-7.
35. de Castro LA, Ribeiro LR, Mesquita R, de Carvalho DR, Felcar JM, Merli MF, et al. Static and functional balance in individuals with COPD: Comparison and differences with healthy controls according to sexual and disease severity. Respir Care. 2016; 61: 1488- 1496.
36. Relationship with static and dynamic imbalance and disease-related factors in patients with chronic obstructive pulmonary disease: A cross-cutting study. Wien Klin Wochenenschr. 2021; 133: 1186-1194.
37. Oliveira CC, Lee AL, McGinley J, Anderson GP, Clark RA, Thompson M, et al. Balance and decreases in acute severity of chronic obstructive lung disease: A future study. COPD. 2017; 14: 518-525.
38. Tudorache E, Oancea C, Avram C, Fira-Mladinescu O, Petrescu L, Timar B. In chronic obstructive lung disease, imbalance and systemic inflammation. Int J Chron Obstruct Lung Dis. 2015; 8: 1847-52.
39. Breslin E, Van Der Schans C, Breukink S, Meek P, Mercer K, Volz W, et al. Fatigue and quality of life perception in COPD patients. Chest. 1998; 114: 958-964.
40. Oliveira CC, Lee AL, McGinley J, Thompson M, Irving LB, Anderson GP, et al. Decreases in individuals with chronic obstructive pulmonary disease: previous 12-month perspective cohort study. Respirology. 2015; 20: 1096- 1101.
41. Gonçalves DFF, Ricci NA, Coimbra AMV. Functional balance among community-dwelling older adults: a comparison of their history of falls. Brazilian Journal of Physical Therapy. 2009; 13: 316-323.
42. Sanseverino MA, Pecchiari M, Bona RL, Berton DC, de Queiroz FB, Gruet M, et al. Factors limiting walking performance in people with COPD. Respiratory care. 2018; 63: 301-310.
43. Ilgin D, özalevli S, Kilç O, Jevinç C, Cimrin AH, Flying ES. Walking speed as a functional capacity indicator in patients with chronic obstructive lung disease. Breast medicine years. 2011; 6: 141-146.
44. Karpman C, DePew ZS, LeBrasseur NK, Novotny PJ, Benzo RP. Detectors of walking speed in COPD. Chest. 2014; 146: 104-110.
45. Saritas Arslan, Relationship of Quadriseps Muscle Strength, Balance and Knee Joint Propriosection to Disease Gravity and Exercise Capacity in M. COPD Patients. Master’s thesis. Istanbul University, University of Health Sciences, Istanbul.
46. Gosselink RIK, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise restriction in COPD. American Journal of Respiratory and Critical Care Medicine. 1996; 153: 976-980.
47. Paddison JS, Effing TW, Quinn S, Frith PA. Fatigue in COPD: association with functional status and hospitalisations. European Respiratory Journal. 2013; 41: 565-570.
48. Gosselink R, Troosters T, Decramer M. Distribution of muscle weakness in patients with persistent chronic obstructive lung disease. Journal of Cardiopulmonary Rehabilitation and Prevention. 2000; 20: 353-360.
49. Borges VS, Silva NS, Malta AC, Xavier CN, Bernardes LES. Elderly women in the society have declines, muscle strength and functional abilities. Physiotherapy in Movimento. 2017; 30: 357-366.
50. Oliveira CC, McGinley J, Lee AL, Irving LB, Denehy L. Fear of falling in people with chronic obstructive pulmonary disease. Respiratory medicine. 2015; 109: 483-489.
51. Pana A, Sourtzi P, Kalokairinou A, Pastroudis A, Chatzopoulos ST, Velonaki VS. Association between self-reported or perceived fatigue and falls among older people: a systematic review. International journal of orthopaedic and trauma nursing. 2021; 43: 100867.
52. Sharon W Renner, Jane A Cauley, Patrick J Brown, Robert M Boudreau, Todd M Bear, Terri Blackwell, et al. Osteoporotic Fractures in Men (MrOS) Study Group, High Fatigue Prospectively Increases the Risk of Falls in Older Men, Innovation in Ageing. 2021; 5: igaa061.
53. özgür ES, Atis S, Kanik A. Effect of dynamic hyperinflation on exercise dyspnoea, exercise capacity and quality of life in COPD. Tuberculosis and Thorax Derg. 2008; 56: 296-303.
54. özkan S. Quality of Life and Functional Status in Chronic Obstructive Pulmonary Disease. Anatolian Journal of Nursing and Health Sciences. 2010; 9: 98-103.
55. Miravitlles M, Molina J, Naberan K, Cots JM, Ros F, Llor C. Factors determining the quality of life of patients with COPD in primary care. Therapeutic advances in respiratory disease. 2007; 1: 85-92.
56. Fazekas-Pongor V, Fekete M, Balazs P, Árva D, Pénzes M, Tarantini S, et al. Health-related quality of life of COPD patients aged over 40 years. Physiology international. 2021; 108: 261-273.
57. Ståhl E Lindberg A, Jansson SA, Rönmark E, Svensson K, Andersson F, Lundbäck B. Health-related quality of life is linked to the severity of COPD. Health and quality of life scores. 2005; 3: 1-8.