Chronic Obstructive Pulmonary Disease and Gait Disturbance: Is There Any Meaningful Link? Unveiling the Interplay and Addressing the Challenges

Abstract

Chronic obstructive pulmonary disease (COPD) is a progressive lung condition characterized by airflow limitation and respiratory symptoms such as shortness of breath, chronic cough, and sputum production. The relationship between COPD and gait disturbance is orchestrated by a complex interplay of factors. Airflow obstruction, the hallmark of COPD, imposes a strain on the respiratory system, leading to breathlessness and fatigue. This relentless struggle for breath forces individuals with COPD to curtail their walking pace, where they adopt a shortened stride and reduced step height. Furthermore, the chronic inflammation associated with COPD infiltrates skeletal muscles, leading to muscle weakness and decreased muscle mass. This insidious process further impairs gait, diminishing the ability to generate the necessary force for efficient ambulation. This chapter will explore the connection between COPD and gait disturbance, examining the underlying mechanisms, prevalence, impact, and management strategies to prevent fall-related injuries and improve the well-being of individuals affected by this challenging combination.

1. Introduction

The intricate dance between chronic obstructive pulmonary disease (COPD) and gait disturbance is orchestrated by a complex interplay of factors. Airflow obstruction, the hallmark of COPD, imposes a relentless strain on the respiratory system, leading to breathlessness and fatigue. This relentless struggle for breath forces individuals with COPD to curtail their walking pace, where they adopt a shortened stride and reduced step height. Furthermore, the chronic inflammation associated with COPD infiltrates skeletal muscles, leading to muscle weakness and decreased muscle mass. This insidious process further impairs gait, diminishing the ability to generate the necessary force for efficient ambulation.

1.1 Prevalence and impact: a widespread affliction and its consequences

Gait disturbance is not a mere footnote in the saga of COPD; it is a prevalent and debilitating manifestation that significantly impacts the lives of individuals affected. Studies have revealed that over 50% of COPD patients experience gait abnormalities, a proportion that escalates with disease severity. This compromised gait not only hinders daily activities but also increases the risk of falls, a major concern among COPD patients, leading to increased healthcare costs and reduced quality of life.

Current research shows that COPD must be considered as a multidimensional condition [1] with side effects that extend well beyond the lungs. Figure 1 demonstrates the systemic manifestations of COPD and health outcomes. It begins with the three primary causes of COPD, which include the airway obstruction due to mucus overproduction, airflow limitation, lung hyperinflation, and gas trapping. Lung hyperinflation occurs when trapped air in the lungs makes full exhalation difficult, causes dyspnea, and increases work of breathing (WOB). The dyspnea and WOB, in turn, lead to exercise intolerance. Exercise intolerance is the inability to perform physical activity due to shortness of breath. The lack of exercise can then lead to inactivity and muscle deconditioning, which is the loss of muscle mass and strength, particularly the peripheral muscles, which further could result in frequent hospitalization due to exacerbation, impaired health status, disability, and premature death [2].

Figure 1.

Consequences of airway obstruction in chronic obstructive pulmonary disease.

To alleviate this burden, the use of technology for health is being recognized as a tool to identify unseen problems and to provide a potentially effective solution for improving care [3].

People with COPD have a range of characteristics and severity. Therefore, it is fundamental to identify high-risk groups who are likely to suffer from multisystem diseases such as arthritis, osteoporosis, diabetes, and cardiovascular instability [4]. This approach would help to develop early interventions in order to achieve meaningful improvement in their health outcomes. Among many symptoms related to COPD, patients also reported extrapulmonary symptoms, such as coordination and balance issues [5].

Thus, it is essential to improve our understanding about the gait disturbances in COPD and strengthen the gait and balance monitoring systems for COPD with robust technology and customized tools. These personalized tools allow these patients to remain independent, seek medical assistance promptly, and prevent chances of complications such as muscle deconditioning, the risk of fall, and subsequent hospitalizations [6].

1.2 Brief overview of COPD and its prevalence

COPD is characterized by persistent airflow limitation in the lungs. It primarily affects the airways and lung tissues, making it difficult for individuals with COPD to breathe properly [7]. The two main pathological forms of COPD are chronic bronchitis and emphysema, although many patients may have a combination of both conditions [8].

COPD is a significant global health issue and one of the leading causes of morbidity and mortality worldwide [9]. According to the World Health Organization (WHO), as of 2021, it was estimated that more than 250 million people suffer from COPD worldwide [10].

It is estimated that there has been a 27% increase in the number of COPD cases within the last 10 years in the UK. Before the COVID pandemic, the direct cost of COPD to the UK’s healthcare system has been estimated at approximately £850 m per annum. The most accurate estimate for the prevalence of diagnosed COPD in England in 2019 among individuals aged 40 years or older is 4.9%. Applying these definitions to the entire population of England using the 2019 mid-year population estimate from the Office of National Statistics suggests that approximately 1.4 million people aged 40 years or older in England have a COPD diagnosis, and an estimated 500,000 are undiagnosed [11].

COPD is a prevalent chronic respiratory disease with substantial global impact. Early diagnosis, prompt intervention, and appropriate management are imperative in improving the quality of life for individuals living with COPD and reducing the burden of this condition on individuals and healthcare systems. Smoking cessation and preventive measures to reduce exposure to risk factors remain essential in curbing both prevalence and complication and/or coexisting conditions, such as gait disturbances.

1.3 Definition and types of gait disturbance

Normal gait is a rhythmic and coordinated pattern of movement that allows humans to walk efficiently and maintain balance. It is characterized by several key features. Figure 2 shows the different phases of the normal gait cycle in humans. The gait cycle is the sequence of events that occurs during one step. It is divided into two main phases: stance phase and swing phase and has several key features, mainly symmetry, stability, efficiency, and smoothness. Firstly, both legs move in a similar manner, with equal stride length and swing time known as symmetry [12]. Stability means that the center of gravity remains relatively stable throughout the gait cycle, minimizing the risk of falls. Efficiency occurs when the muscles work together in a coordinated manner to generate the necessary force for propulsion with minimal energy expenditure. Smoothness refers to a smooth and effortless motion free of jerky or awkward motions [13].

Figure 2.

Phases of a normal gait cycle. Source [12].

Gait disturbance refers to abnormal walking patterns or difficulties in maintaining a stable and coordinated gait. It is a common issue observed in various medical conditions, affecting mobility, balance, and overall functional abilities [14]. Gait disturbances can vary in severity and presentation, depending on the underlying cause. Gait speed, chair rise time, and the ability to tandem walk are independent predictors of the ability to do daily and instrumental activities of living and of the risk of nursing home admission and death [15].

2. Connections between COPD and gait disturbance

2.1 Prevalence and risk factors for gait disturbance in COPD patients

Consistent evidence shows gait disturbances among people with COPD [16, 17, 18]. The prevalence of gait disturbances in COPD patients depends on the severity of the disease, the presence of comorbidities, and the age of the individual. Studies have reported that gait disturbances can affect up to 60% of COPD patients, particularly those with more advanced disease stages [19].

Several risk factors cause gait impairments in people with COPD both directly related to the underlying lung condition and indirectly associated with the age, drugs, lifestyle, and overall health status of the individual [20].

However, the key risk factor that may disrupt balance is muscle weakness. COPD is associated with muscle wasting and weakness, especially in the respiratory muscles and the lower extremities. Weak leg muscles can significantly impact gait stability and lead to walking difficulties [21, 22].

Another potential factor is a reduced exercise capacity. COPD patients often experience exercise intolerance due to impaired lung function, which leads to reduced physical activity [23]. Lack of regular exercise can contribute to deconditioning and further exacerbate gait disturbances.

In addition, breathlessness, which is a hallmark symptom of COPD, particularly individuals with severe dyspnea (shortness of breath), may lead the patient to adopt altered gait patterns to minimize exertion and oxygen demand [24].

Another potential factor is that COPD patients may experience balance problems caused by either muscle weakness or impaired proprioception (sense of body position) [25]. Balance issues can lead to an unsteady gait and an increased risk of falls [26]. In addition, some medications used to control symptoms in COPD, such as bronchodilators or systemic corticosteroids secondary to musculoskeletal abnormalities, can cause muscle weakness or dizziness, which may, in turn, lead to gait-related issues [27, 28, 29].

Furthermore, COPD is associated with other chronic conditions and/or complications, such as cardiovascular diseases, osteoporosis, and neurological disorders, which can contribute to gait disturbances [30]. Another integral factor that could be related to balance impairment is smoking, which is a significant risk factor for COPD development [31]. Smoking is known to have an impact on vascular health and contribute to peripheral artery disease or nerve damage, affecting gait [32].

Additionally, unhealthy lifestyle habits and a lack of physical activity can further exacerbate gait issues [33]. Also, COPD is more prevalent in older individuals and age-related changes in muscle strength, joint flexibility, and balance can contribute to gait disturbances in this population [34]. Moreover, COPD patients usually have a range of severity from mild to moderate and severe that causes respiratory muscle weakness and deconditioning, which can influence gait patterns [35].

Therefore, understanding the risk factors for gait disturbance in COPD patients is essential for healthcare professionals to develop appropriate management strategies. Pulmonary rehabilitation, which includes exercise training, can help improve muscle strength and exercise tolerance, leading to better gait stability. Additionally, fall risk assessments and interventions to improve balance can help reduce the risk of falls in COPD patients with gait disturbances.

2.2 Impact of gait disturbance in patients with COPD

2.2.1 Physical and psychological well-being

The altered walking pattern and reduced mobility can affect various aspects of a person’s life, leading to functional limitations and emotional challenges. Both the physical and psychological well-being are affected, [36] especially for those individuals with various long-term diseases, such as COPD, which is a heterogeneous condition with multiple phenotypes and endotypes [37].

Gait disturbances can hinder a person’s ability to move around independently and perform activities of daily living. Thus, the sufferers become partly dependent to perform activities of daily living on their partner, spouse, family, and/or social support agencies. An unsteady gait can significantly increase the risk of falls, particularly in older adults and in those with weakened muscles or balance impairments. Falls can result in injuries, fractures, and hospitalization, leading to a decline in overall physical health [38].

2.2.2 Muscle fatigue and discomfort

Individuals with gait disturbances may experience muscle fatigue and discomfort due to compensatory movements or abnormal weight distribution while walking [39]. This discomfort can lead to increased energy expenditure and decreased endurance during walking. In patients with COPD, gait disturbances can aggravate breathing difficulties [40].

The additional physical effort required to walk can exacerbate dyspnea, leading to reduced exercise tolerance and further limitations in physical activities [41].

2.2.3 Impact on psychological well-being

Gait disturbances can lead to a loss of independence and to a sense of reliance on others for care and daily tasks [42]. This loss of autonomy can result in feelings of frustration, helplessness, and low self-esteem [43].

Furthermore, anxiety and fear of falling are higher in individuals with gait disturbances, which can be debilitating and lead to social isolation and limitation of their activities that require standing and/or walking such as bathing, walking, exercising, and shopping. This fear of falling may discourage individuals from engaging in physical activities and social interactions [44].

2.2.3.1 Depression and social isolation

The limitations imposed by gait disturbances in people with chronic conditions, such as COPD, can lead to feelings of sadness, hopelessness, and depression [45]. Moreover, social isolation is another adverse consequence of balance and gait impairment that may well cause feelings of loneliness and further exacerbate emotional distress [46].

2.2.3.2 Reduced quality of life

The combination of physical limitations and emotional challenges can significantly reduce the overall quality of life for individuals with gait disturbances. Their ability to engage in meaningful activities and enjoy life may be compromised [46].

Therefore, recognizing the impact of gait disturbance on physical and psychological well-being is essential in developing comprehensive care plans for affected individuals.

Multidisciplinary approaches, including physical therapy, pulmonary rehabilitation, and psychological support, can help improve mobility, manage anxiety and depression, and enhance overall well-being. Providing assistive devices and mobility aids can also promote independence and reduce the risk of falls, enabling individuals to maintain an active and fulfilling lifestyle despite gait disturbances.

2.3 Mechanisms linking COPD to gait disturbance

The mechanisms linking COPD to gait disturbance involve a combination of respiratory and musculoskeletal factors that include airflow limitation, dyspnea, hyperinflation, exacerbation, smoking, steroid use, and respiratory muscle weakness [47].

2.3.1 Airflow limitation

COPD causes chronic airflow limitation, leading to increased work of breathing. The respiratory muscles, including the diaphragm and intercostal muscles, weaken due to the constant effort required to overcome airflow obstruction. This weakness affects breathing during physical activities, such as walking [48].

2.3.2 Dyspnea

COPD patients may experience breathlessness while walking, altering breathing patterns and potentially affecting consistently lower body oxygen and higher carbon dioxide levels, which may lead to altered blood pH, muscle tissue destruction, and muscle weakness. The effect on muscles could be one of the risk factors for balance impairments in this cohort [49].

2.3.3 Muscle wasting, weakness, and deconditioning

Chronic inflammation in COPD can cause muscles, including those involved in walking, to waste, and lose muscle mass. Lower limb muscle weakness affects gait stability and body weight support [50]. Reduced exercise capacity and physical activity limitations in COPD lead to deconditioning, further exacerbating muscle weakness, endurance, and gait abnormalities [51].

2.3.4 Reduced exercise capacity

The combination of impaired lung function and respiratory muscle weakness significantly reduces exercise capacity and tolerance in COPD patients. Exercise capacity refers to the maximum amount of work a person can perform before becoming fatigued. Exercise tolerance, on the other hand, refers to the ability to sustain physical activity for a prolonged period. The reduced exercise capacity and tolerance may lead to compensatory mechanisms during walking, such as slower pace or avoiding strenuous activities [52].

2.3.5 Decreased ventilation-perfusion matching

Ventilation-perfusion (V/Q) mismatch is a major contributing factor to COPD pathology. With V/Q mismatch, the blood in the capillaries does not receive enough oxygen from the air in the alveoli. This oxygen-deprived blood then travels to the muscles, where it cannot provide the necessary oxygen for muscle contraction. As a result, the muscles become weak and fatigued, which can lead to gait impairment. COPD leads to uneven distribution of ventilation and blood flow in the lungs, affecting gas exchange. This can reduce oxygen delivery to muscles during physical activities, impacting gait [53, 54].

2.3.6 Reduced proprioception

COPD patients may experience balance issues, resulting from reduced proprioception, vestibular dysfunction, or musculoskeletal limitations. These impairments contribute to an unsteady gait and increase fall risk [55].

COPD is a progressive lung disease that can significantly impact mobility and increase the risk of falls. One of the key factors contributing to gait disturbances and falls in COPD patients is balance dysfunction. Balance is a complex process that involves the integration of sensory information from the visual, vestibular, and proprioceptive systems along with the coordinated action of the musculoskeletal system.

Reduced proprioception is a common impairment in COPD patients. This sensory deficit can arise from damage to sensory receptors in the muscles, joints, and tendons, often as a result of chronic inflammation and deconditioning associated with COPD. When proprioception is impaired, individuals have difficulty perceiving their body’s position and movement in space, making it challenging to maintain balance and stability during walking or standing.

Vestibular dysfunction, another contributing factor to balance issues in COPD patients, originates from abnormalities in the inner ear, which plays a vital role in regulating balance and spatial orientation. Vestibular dysfunction can manifest as dizziness, vertigo, or a sense of unsteadiness, further compounding the challenges of maintaining balance during ambulation.

2.3.7 Medication side effects

Medications used to treat COPD can sometimes cause gait impairment and balance issues. These issues occur because some COPD medications, such as beta-blockers and corticosteroids, can have side effects that affect the muscles and nerves involved in movement [56]. These side effects can include weakness, muscle wasting, and muscle cramps. As a result, people with COPD who are taking these medications may experience difficulty walking, balance problems, and an increased risk of falls.

It is important to note that not all people with COPD will experience gait impairment or balance issues caused by their medication. The risk of these side effects is also increased by other factors such as age, smoking history, and underlying medical conditions. Patients concerned about gait impairment or balance issues should talk to their doctor, who can help to identify whether a medication is causing these problems and can recommend alternative treatment options or additional interventions, such as physical therapy, to help improve mobility.

2.3.8 Coexisting comorbidities

COPD often coexists with other conditions, such as cardiovascular diseases or neurological disorders, which can influence gait mechanics and contribute to gait disturbances.

Some of the most common comorbidities that can contribute to balance impairment in COPD include heart disease, neuromuscular disorders, arthritis, and osteoporosis. Heart disease and stroke can both affect balance by reducing blood flow to the brain and inner ear. Neuromuscular diseases, such as Parkinson’s disease and multiple sclerosis, can damage the nerves and muscles that control balance.

Arthritis can cause pain and stiffness in the joints, which can make it difficult to move and maintain balance. Diabetes can damage the nerves and blood vessels in the feet, which can lead to balance problems. Osteoporosis is a condition that weakens the bones, which can make them more likely to break in a fall [56].

Regular assessment and effective management of comorbidities, combined with targeted interventions, can significantly improve gait function and overall quality of life in COPD patients.

2.3.9 Systemic inflammation

COPD’s chronic inflammatory state can have systemic effects on muscle function and overall physical performance. Studies have shown a strong correlation between the severity of systemic inflammation in COPD patients and the degree of balance impairment [57]. Patients with higher levels of inflammatory biomarkers exhibit poorer performance on balance tests and a higher risk of falls.

Therefore, systemic inflammation is associated with gait disturbances in individuals with COPD, impacting mobility, balance, and overall functional abilities. Addressing these factors through pulmonary rehabilitation, physical therapy, and targeted interventions can help improve gait and overall quality of life for affected individuals.

Therefore, it is an unmet need to address systemic inflammation in COPD patients, and it may be a good strategy for improving balance function and reducing the risk of falls. Anti-inflammatory medications, such as corticosteroids, have shown some benefit in improving balance in COPD patients [58]. Additionally, lifestyle modifications, such as smoking cessation, regular exercise, and weight management, can help reduce systemic inflammation and potentially improve balance.

2.4 Explanation of gait disturbance and its significance in COPD patients

A growing body of evidence shows that individuals with COPD have critical deficits in balance control that may be associated with gait disturbances and increased risk of falls. The studies reported a fall rate of up to 50% in this population. The presence of balance deficits and gait disturbances has been identified as a significant risk factor for falls in COPD patients [59, 60, 61, 62]. Furthermore, the long-term alteration of posture (breathing at a high lung volume [hyperinflated lungs], which causes a slight backward displacement of the thorax and high shoulder position), muscle dysfunction, and the use of steroids, may lead to breathing and gait disturbances [12, 63]. The current findings suggest that COPD patients, in most severe cases, walk less than 15 minutes per day [5].

Moreover, COPD patients walk slower than other people of the same age and have a higher incidence of falls per 1000 people compared with non-COPD subjects. The incidence was 44.9 per 1000 person-years (95% CI 44.1–45.8) for COPD subjects and 24.1 per 1000 person-years (95% CI 23.8–24.5) for non-COPD subjects [16].

COPD cohorts are identified by a range of features, such as a barrel-shaped chest caused by hyperinflation, as shown in Figure 3. A barrel-shaped chest, also known as a hyperinflated chest, is a common symptom of COPD. It results from the trapping of air in the lungs due to narrowed airways and damaged alveoli [64]. This air trapping can lead to several anatomical and physiological changes that contribute to gait disturbances in COPD patients.

Figure 3.

A normal and a barrel-shaped chest.

Other factors, including severity of disease and lifestyle limitations, are important to understand and explore to prevent gait disturbances. Early intervention to mitigate these disturbances can also improve health outcomes. Thus, it is important to strengthen the monitoring systems using robust technology to evaluate their extrapulmonary manifestations and develop technology-centered models and tools that allow these patients to remain independent, motivated, and stable to avoid complications, such as decompensation and hospitalizations.

In addition, COPD people showed a statistically significant reduction, compared to controls, in the stiffness coefficient and viscous damping of the knee joint, as determined from experiments where the leg is allowed to swing freely after being released from a given angle [65, 66]. These measurements indicate degeneration of the knee tissues. During voluntary flexion-extension movements, electromyography recordings revealed lower activity in the rectus femoris and biceps femoris muscles of COPD patients compared to controls. This reduced muscle activity, likely due to the low viscoelastic tension observed in the patients, contributed to impaired movement performance. These findings offer new perspectives on the underlying mechanisms responsible for movement limitations associated with COPD. Also, Karmpan and co-workers [16] found gait speed as a measure of functional status in COPD individuals is strongly correlated with disease outcomes (Figure 4). The arrows in the diagram indicate the direction of the associations. For example, the arrow from lung function to gait speed indicates that people with poor lung function have slower gait speed. This also highlights the fact that exercise capacity is not only the primary determinant of gait speed but also reflects a broader picture of health in COPD patients.

Figure 4.

The relationship of gait speed with physiological parameters in COPD [16].

It is important to note that the associations between gait speed and the other variables in the diagram are complex and can be influenced by a number of other factors such as medication use, comorbidities, and lifestyle choices. This complexity arises because it encompasses the interplay of various systems affected by disease severity rather than just lung function alone. As a result, gait speed serves as a valuable screening tool for both exercise capacity and frailty.

In COPD, the usual gait speed measured over a 4-meter course with a rolling start accurately identifies clinically meaningful benchmarks of the 6-minute walk test. Notably, a specific cut-off point of 0.8 m/s has a high positive predictive value (69%) for identifying very poor exercise capacity and an even higher negative predictive value (98%) [67].

The growing body of evidence on gait speed is promising, suggesting its potential as a simple test that comprehensively informs clinicians about various functional aspects of a COPD patient’s health. Future research is likely to further demonstrate its strength as a predictive marker for hospitalizations, readmissions, and even mortality.

However, the current assessments of COPD, which are mainly focused on improving symptoms and monitoring disease, do not fully reflect the multisystem impact of the disease. It is, therefore, a vital prerequisite to adapt a holistic approach to managing people with COPD such as promoting physical activity with a higher level of acceptability and mobility that is safe, effective, reliable, and prevents the risk of fall.

Therefore, the functional gait assessment (FGA) to assess postural stability and balance during pulmonary rehabilitation (PR) in COPD populations would identify abnormalities and sensorimotor postural deficiencies. This assessment provides clinicians an opportunity to improve health outcomes in the COPD population. Also, the current international guidelines do not include balance training and fall prevention strategies, which, in turn, lead to risk of fall and impaired quality of life. However, due to limited research in this area, small sample sizes, gender differences, and disease severity, there is lack of evidence to understand the mechanistic link found between such gait impairments and falls in patients with COPD. This suggests that it is important for clinicians to be open-minded to understand the extent and type of support needed to cater to people with COPD. PR is a key therapeutic intervention for individuals with COPD. This situation raises the opportunity to use advanced technology to examine the biomechanics in people with COPD and understand the gait-related impairments these patients have as a guide to develop further accurate standardized assessment tools to identify and manage these impairments.

Gait assessment and rehabilitation for COPD patients extend beyond simply physical exercises. Research suggests that incorporating cognitive stimulation into the process can significantly improve overall outcomes [67, 68, 69]. This includes factors such as engagement, motivation, and adherence, which play a crucial role in patient performance and progress.

However, social robots are emerging as innovative tools in healthcare, offering promising benefits for COPD patients undergoing gait rehabilitation. Their physical embodiment and capabilities in social and emotional intelligence contribute to a more engaging and cognitively stimulating experience for users [57, 70]. This, in turn, leads to improved user engagement, task performance, motivation, and ultimately, adherence to the rehabilitation program [19, 71].

The integration of social robots in rehabilitation can have benefits and distinct advantages. One advantage is one-on-one support; social robots provide personalized support, enabling healthcare professionals to dedicate more time and attention to individual patient needs [59]. Also, robots can be utilized as a tool for gait assessment, complementing traditional methods and providing valuable data for healthcare professionals to analyze and tailor treatment plans accordingly [63].

Furthermore, the engaging and motivating nature of social robots can significantly improve patient adherence to the rehabilitation program, leading to better long-term outcomes, [71] and can provide both physical and cognitive assistance, contributing to improved gait performance and overall well-being [57].

3. Approaches to combat COPD-induced musculoskeletal impairments

Several mechanisms contribute to gait impairments in patients with COPD. These include muscle loss, particularly in the legs, due to decreased physical activity. This loss can lead to instability and difficulty walking. Another cause is breathlessness as almost all COPD patients often experience breathlessness, which can further limit their physical activity and contribute to muscle weakness. Furthermore, changes in the lung mechanics, such as hyperinflation and air trapping within the lungs, can lead to changes in posture and gait. Lastly, the psychological fear these patients have can lead to symptoms, such as cough or shortness of breath, which can lead them to avoid activities and lose confidence to do daily activities independently or without support.

These mechanisms collectively have a significant impact on the quality of life of COPD patients. They can also lead to reduced independence, increased social isolation, and increased risk of falls or other serious injuries. The gait issues can increase healthcare costs through more frequent doctor visits, hospital admissions, and long-term care.

3.1 Therapy-based solutions for COPD-induced gait problems

Potential solutions for COPD-induced gait problems include pulmonary rehabilitation (PR), physical therapy (PT), and occupational therapy (OT). The PR program of exercise, education, and support can help COPD patients improve their lung function, physical activity levels, and level of independence. PT can help COPD patients improve their muscle strength, balance, and coordination. A less common intervention, OT, can help COPD patients learn how to modify their daily activities to make them easier and safer. A potentially more effective support can be provided to COPD patients through assistive devices (e.g., canes, rollers) and robot-aided technology.

3.2 Assistive devices

The most emerging solution is the use of assistive technology. Assistive technology can help COPD patients walk more easily and safely. Assistive technologies that can benefit COPD patients with gait problems include:

• Canes: canes can provide support and stability for COPD patients who are at risk of falls [72].

• Walkers: walkers can provide even more support and stability than canes. They can also be used to carry items, such as groceries or oxygen tanks [73].

• Rollators: rollators are walkers with wheels that allow COPD patients to roll instead of walk. The addition of wheels can be helpful for patients who have difficulty walking due to breathlessness or fatigue [74].

• Electric wheelchairs: electric wheelchairs can be used by COPD patients who are unable to walk at all [75].

3.3 Advantages of robot-aided rehabilitation

Robot-aided rehabilitation: robot-aided rehabilitation is a new and emerging technology that is being used to help COPD patients improve their gait. Robots can provide support, guidance, and feedback to help patients learn to walk again.

Robot-aided rehabilitation has several potential advantages over other forms of rehabilitation. It can provide more consistent and reliable support than is provided by human therapists.

• Robots can be programmed to provide customized exercises for each patient.

• Robots can be used to provide rehabilitation in patients’ homes, which can be more convenient and affordable than attending therapy sessions at a clinic.

A recent study showed that robot-aided gait rehabilitation improved gait speed, balance, and quality of life in patients with chronic conditions, such as stroke and Parkinson’s [76, 77]. The study also found that robot-aided rehabilitation was more effective than traditional physical therapy.

Overall, evidence is growing that robot-aided rehabilitation is a promising new method to treat gait problems in COPD patients. Further research is needed to determine the long-term benefits of robot-aided rehabilitation and to identify the best ways to use this technology in clinical practice.

The technological developments in the healthcare industry have ameliorated health outcomes in patients with chronic diseases such as COPD by improving their quality of life, promoting independence, and encouraging a self-management approach. The use of technology in the medical field also reduces the hospital burden, which has had a massive impact on many practices of healthcare professionals. Smartphones, tablets, and PCs may help people who have COPD and are living at home as these devices can provide information, education, and guidance on the development of their condition. These technologies can recommend appropriate exercise programs or give advice on how to stop smoking; however, they fail to prove useful for the prevention of musculoskeletal impairments derived from COPD. Further, research is needed to harness the potential of state-of-the-art technology to gain a better understanding of COPD-derived motor impairments and act upon them to improve patients’ health condition.

Apart from social encouragement to motivate further exercise, several technologies exist that allow a physical intervention to correct posture and gait patterns. Diverse exoskeletons have been designed to support daily activities, such as the Wearable Walking Helper [WWH] [78], the McKibben pneumatic muscles orthosis [79], or the exoskeleton for patients and the old [EXPOS] by the Sogang University [80]. Exoskeletons, such as the Ekso GT, improve balance and impact functional status in the recovery of patients with stroke [81].

Assistive devices are also of relevant interest for younger patients with life-long disabilities who wish to complement their locomotion skills. For instance, recent advancements allowed patients with spinal cord injuries to “be walked” within an exoskeleton so that they [re]experience bipedal walking and standing. For example, Ekso [Ekso Bionics, US, formerly eLEGs] [81] allowed subjects to walk, stand up, and sit down. Another example is the ReWalk [82], which enabled people with paraplegia to perform ambulatory functions. Also, the HAL robot was reported to enable a paraplegic patient to walk [83, 84].

Though exoskeletons are becoming popular, with many research institutions and companies developing such devices as Honda [American Honda Motor Co., Inc.] [85]. Few publications refer to their design and control characteristics and to the effects of wearing the device [86, 87]. Moreover, most of these devices have been designed as prototypes, being mostly tested with healthy young people so far, with few being used in the market. More importantly, to my knowledge, there is no literature, and no research has been done in the development or use of these devices to aid patients with COPD.

3.4 Limitations and challenges of robot-aided rehabilitation

While robot-aided rehabilitation could revolutionize the treatment of gait problems in COPD patients, some limitations and challenges need to be addressed:

• Cost: robot-aided rehabilitation systems are expensive [88].

• Availability: robot-aided rehabilitation systems are not yet widely available [89].

• Training: therapists need to be trained on how to use robot-aided rehabilitation systems [90].

• Patient acceptance: some patients may be uncomfortable or resistant to using robot-aided rehabilitation systems [91].

Despite these limitations, robot-aided rehabilitation is a promising new technology that has the potential to improve the lives of COPD patients with gait problems.

4. Conclusion

COPD is a progressive respiratory condition that can significantly impact mobility and increase the risk of falls. Gait disturbances in COPD are characterized by slower walking speed, shorter steps, and increased variability in gait patterns. These changes can be attributed to a combination of factors, including airway obstruction, muscle weakness, dyspnea (breathlessness), and deconditioning.

Gait impairments are a significant and often under-recognized aspect of COPD. This chapter has explored the intricate relationship between this chronic respiratory condition and gait function, highlighting the multifaceted nature of this complex interaction. We have delved into the physiological, biomechanical, and psychological factors that contribute to gait abnormalities in COPD patients, encompassing topics such as exercise capacity, muscle weakness, dyspnea, and anxiety.

The evidence presented underscores the critical role of gait assessment in the comprehensive management of COPD. Early identification and monitoring of gait impairments are compelling for optimizing rehabilitation strategies, reducing fall risk, and improving overall quality of life. Integrating various assessment tools, including functional tests, gait analysis, and potentially, socially assistive robots, can provide valuable insights into individual patient needs and inform personalized interventions.

Emerging technologies, such as wearable sensors and exoskeletons, offer exciting possibilities for further augment gait rehabilitation in COPD patients. These tools can provide real-time feedback, facilitate targeted interventions, and track progress objectively, leading to more effective and individualized treatment plans.

Looking beyond the immediate impact on gait, the broader implications of the COPD-gait connection are significant. Gait impairments can affect daily activities, social participation, and mental well-being, leading to a reduced quality of life for COPD patients. By addressing these challenges through comprehensive gait rehabilitation programs, we can empower individuals with COPD to maintain their independence, boost their social engagement, and improve their overall well-being.

Furthermore, in this chapter robot-aided technology has emerged as a promising intervention to prevent fall risk in COPD patients. These technologies offer several advantages, including:

Fall detection and alert systems: wearable sensors or smart home devices can detect falls or near-falls and immediately trigger an alarm, notifying caregivers or emergency services. This prompt intervention can significantly reduce the time spent on the ground, minimizing the risk of serious complications.

Gait and balance assistance: robotic exoskeletons or wearable devices can provide real-time support during ambulation, helping to stabilize gait, improve balance, and reduce the risk of tripping or falling. These devices can be particularly beneficial for patients with severe gait disturbances or those who have experienced recurrent falls.

Rehabilitation and exercise support: robotic-assisted rehabilitation programs can provide personalized and intensive gait and balance training, helping patients regain strength, improve coordination, and strengthen their overall mobility. These programs can be customized to individual patient needs and can be tailored to different stages of COPD progression.

Environmental monitoring and assistance: smart home technology can monitor the patient’s environment, such as detecting low lighting or slippery floors, and can trigger appropriate interventions, such as turning on lights or activating fall prevention mats. These proactive measures can help to reduce the risk of falls by addressing potential hazards in the home environment.

Telehealth and remote monitoring: robot-aided technology can facilitate remote monitoring of COPD patients, allowing healthcare providers to assess gait patterns, track progress, and provide personalized support and guidance. This can be particularly beneficial for patients in rural or underserved areas who may have limited access to in-person care.

Psychological support and fall prevention education: robot-assisted technology can provide psychological support and fall prevention education, helping patients to develop coping mechanisms, manage anxiety, and adopt safer movement strategies. These interventions can, further, enhance fall prevention efforts by addressing psychological factors that may contribute to fall risk.

Integration of robot-aided technology into COPD care may significantly reduce fall risk and improve mobility outcomes for these patients. By providing personalized support, real-time monitoring, and remote intervention capabilities, these technologies can play a crucial role in reviving the quality of life and safety of individuals living with COPD.

By implementing these strategies, healthcare providers and caregivers can effectively support COPD patients with gait and balance issues, improving their mobility, reducing fall risk, and lifting their overall quality of life.

The future holds immense potential for further advancements in understanding and addressing the complex relationship between COPD and gait. Continued research efforts are needed to explore the efficacy of innovative technologies, develop new therapeutic strategies, and improve the overall management of gait impairments in COPD patients. This multifaceted approach is preeminent for ensuring that individuals with COPD can lead active and fulfilling lives.