The co-creation of personalised, multifaceted balance training delivered alongside pulmonary rehabilitation to reduce falls risk for people with Chronic Obstructive Pulmonary Disease

Background A greater proportion of people with COPD fall than healthy age-matched adults (40-55% v 30%) due to balance impairment, as a consequence of more pronounced deficits in the proprioceptive system and motor response. Balance strategies adopted by healthy older adults are inhibited by symptoms and inactivity.

Physiological mechanisms partly explain falls but social deprivation is also important. Pulmonary rehabilitation is standard care to decrease breathless but balance training is required to reduce falls risk.

I am the UK principal investigator on an international trial investigating the effect of pulmonary rehabilitation with balance training on 12-month falls rate. Although ongoing, this trial raises fundamental questions regarding: 1.

Mechanisms This information will enable balance training to be personalised according to the needs of people with COPD by attending to deficits in neuromuscular function.

Discussions with investigators from the international trial indicate that people in Middleborough, an area of high deprivation, fall 8 times more so social/environmental context also needs to be understood. 2. Activate engagement Adherence to pulmonary rehabilitation is poor (42%) and behavior-change needs to be supported. 3.

Promote sustainability Benefits of pulmonary rehabilitation diminish after 12-weeks without maintenance. Balance training needs to be embedded into peoples' everyday lives. Research questions 1. How can balance training be personlised for people with COPD? 2. How can active engagement be encouraged? 3.

How can balance training be embedded into people's everyday lives? Methods Stage 1 (1-21m).

Behavioural component: Update a systematic review extracting the active ingredients of interventions (e.g. behaviour-change techniques and treatment fidelity) to improve balance and quantify the individual intervention response heterogeneity.

Physiological component: Twenty people with COPD and 20 healthy age-matched adults will complete neuromuscular and balance tests.

I will investigate the relationship between tests and between-group differences to identify a variable(s) assessing neuromuscular function.

Psychosocial component: Observe 10 patients/carers in their homes and have informal discussions to understand the lived experience of people with COPD. Stage 2 (22-24m).

Synthesise findings to co-create personalised, multifaceted balance training for people with COPD and a clinician-training package (beta protocol). Two stakeholder/clinician/patient workshops will refine balance training (alpha protocol). Stage 3 (25-63m). All elements of a definitive trial will be piloted.

Forty people with COPD will be randomised to 7-weeks of pulmonary rehabilitation with or without balance training, before a 6-month supported home programme. I will investigate any improvements in balance and if these relate to neuromuscular function. Monthly phone calls will monitor falls and treatment adherence.

Support needs to sustain balance training will be identified using an ethnographic approach, consisting of time-series home-based observations and rapid-informal interviews (total n=24 observations) with patient/carer dyads assigned to balance training. A fidelity assessment and economic evaluation will run alongside the pilot-RCT.

Anticipated impact and dissemination Eight pulmonary rehabilitation roadshows targeted at socially deprived areas of the UK will deliver training based on the clinician-training package. One show will be recorded for web-based dissemination. Experts in digital design and ideation will support innovative ways to disseminate findings publically.

Findings will be published in scientific journals.