Effect of pulmonary function on cardiorespiratory condition, mobility, and balance in people aged over 50 years: a cross-sectional study

Efecto de la función pulmonar en la condición y respuesta cardiorrespiratoria, movilidad y equilibrio en personas mayores de 50 años: un estudio transversal

ABSTRACT

This study aimed to evaluate the effect of static pulmonary function variables on cardiorespiratory condition, mobility, and balance in people aged over 50 years, as well as the effect of mobility and balance on three stress tests in the same sample. This is a cross-sectional study. Pulmonary function evaluation was performed by spirometry, the incremental shuttle walking test (ISWT), the six minute walk test (6MWT), the stairs test (ST), the timed up and go test (TUGT), and the Berg balance scale (BBS). SigmaStat^® was used for statistical analysis, and the variables were correlated using Pearson’s correlation test (p<0.05). The sample consisted of 46 people [37 women (80.5%) and nine men (19.5%)] with a mean age of 61.02±8.29 years. Results of the correlation of pulmonary function with stress, mobility, and balance and stress tests were correlated with spirometric variables. In the sample, people with lower time in TUGT and better balance conditions who had better lung function. The better the mobility, the better the results in the stress tests. TUGT results showed moderate correlation with ISWT (0.41) and actual 6MWT (−0.43). On the other hand, BBS scores showed moderate correlation with ISWT(%) ((−-0.45), real 6MWT (0.43), and actual (−0.59) and predicted ST (-0.45). We conclude that pulmonary function affects cardiorespiratory condition, mobility, and balance in people aged over 50 years.

Keywords
Aging; Pulmonary Function; Mobility; Balance

RESUMO

O objetivo deste estudo foi avaliar o efeito das variáveis de função pulmonar estática na reposta cardiorrespiratória, na mobilidade e no equilíbrio de pessoas acima de 50 anos. E também, na mesma amostra, o efeito da mobilidade e do equilíbrio em três diferentes testes de esforço. O estudo é do tipo transversal. Foi realizada avaliação da função pulmonar por meio da espirometria, incremental shuttle walking test (ISWT), teste de caminhada de seis minutos(TC6), teste de escada (TEsc), teste timed up and go (TUG) e escala de equilíbrio de Berg (BERG). Para análise estatística foi utilizado software SigmaStat^®, as variáveis foram correlacionadas por meio do teste de correlação de Pearson (p<0,05). A amostra foi composta por 46 pessoas sendo 37 (80,5%) mulheres e 9 (19,5%) homens, com idade média de 61,02±8,29 anos. Os resultados de correlação da função pulmonar com os testes de esforço, mobilidade e equilíbrio os testes de esforço apresentaram correlação com as variáveis espirométricas. Na amostra, as pessoas com menor tempo no TUG e melhores condições de equilíbrio foram os que apresentaram melhor função pulmonar. Quanto melhor a mobilidade melhor os resultados nos testes de esforço. Os resultados do TUG apresentaram moderada correlação com ISWT (0,41) e TC6 real (-0,43). Já a pontuação do BERG apresentou moderada correlação com ISWT(%) (-0,45), TC6 real (0,43) e tTEsc (real (-0,59) e predito (-0,45)). Conclui-se que a função pulmonar tem efeito sobre a condição e resposta cardiorrespiratória, mobilidade e equilíbrio em pessoas acima de 50 anos.

Descritores
Envelhecimento; Função Pulmonar; Mobilidade; Equilíbrio

RESUMEN

El objetivo de este estudio fue evaluar el efecto de las variables estáticas de la función pulmonar sobre la respuesta cardiorrespiratoria, en la movilidad y en el equilibrio en personas mayores de 50 años. En la misma muestra, también se analizó el efecto de la movilidad y del equilibrio en tres pruebas de esfuerzo diferentes. El estudio es transversal. La función pulmonar se evaluó mediante espirometría, prueba de caminata de carga progresiva (ISWT), prueba de caminata de seis minutos (PC6M), prueba de escalera (TESc), prueba timed up and go (TUG) y escala de equilibrio de BERG (BERG). Para el análisis estadístico, se utilizó el software SigmaStat^®, las variables se correlacionaron mediante el uso de la correlación de Pearson (p<0,05). La muestra estuvo compuesta por 46 personas, de las cuales 37 (80,5%) eran mujeres; y 9 (19,5%), hombres, con una edad media de 61,02±8,29 años. Los resultados de la correlación de la función pulmonar con las pruebas de esfuerzo, movilidad y equilibrio mostraron correlación con las variables espirométricas. En la muestra, las personas con el menor tiempo en TUG y mejores condiciones de equilibrio tuvieron la mejor función pulmonar. Cuanto mejor sea la movilidad, mejores serán los resultados en las pruebas de esfuerzo. Los resultados de TUG mostraron una correlación moderada con ISWT (0,41) y PC6M real (-0,43). La puntuación de BERG presentó una correlación moderada con ISWT(%) (-0,45), PC6M real (0,43) y tTEsc [real (-0,59) y predicho (-0,45)]. Se concluye que la función pulmonar tiene un efecto sobre la condición y la respuesta cardiorrespiratoria, la movilidad y el equilibrio en personas mayores de 50 años.

Palabras clave
Envejecimiento; Función Pulmonar; Movilidad; Equilibrio

INTRODUCTION

The world population is experiencing an aging process, and it is estimated that this population will have quadrupled by 2050¹. This process can change their mobility and balance, as well as decrease oxygen consumption, cardiac output, and heart rate, that is, a decrease in cardiopulmonary capacity².

People aged 50 years can already show the effects of aging, such as loss of strength and muscle mass, which can decrease their mobility, physical disability, and functional independence. These changes are smaller in active people aged below 50 years, making them less susceptible to age-related diseases³.

The respiratory system also changes with aging, including to the lungs, rib cage, respiratory muscles, and respiratory drive. These changes decrease inspiratory capacity, which, added to the weakness of the respiratory muscles (that is, decreased lung elasticity) decreases expiratory flow and increases residual volume, leading to greater respiratory limitations and thus to a decreased functional capacity⁴ and an increased morbidity and mortality rate in this population⁵.

People with decreased functional capacity may show loss of mobility and increased risk of fall¹ , ⁶. Respiratory muscle strength correlates with mobility, as assessed by the Berg balance scale⁷. Tests that distinguish people under a higher or lower risk of falls are important and should be able to find changes in functional capacity, balance, and mobility⁸.

Considering that aging is a process and that respiratory functional and balance changes take place over time, evaluating people that are yet to be considered older adult will enable the understanding of how respiratory function and functional cardiorespiratory capacity influences balance and mobility. From this, it will be possible to design strategies that can maintain these functions, decreasing falls and their consequent disabilities and improving the quality of life of the older adults.

This study aimed to evaluate the effect of static pulmonary function variables on cardiorespiratory condition, mobility, and balance in people aged over 50 years, as well as the effect of mobility and balance on three different stress tests in the same sample.

METHODOLOGY

This cross-sectional study was conducted in a properly air-conditioned room, corridor, and staircase under shade at the School of Philosophy and Sciences at Universidade Estadual Paulista in the municipality of Marília, São Paulo, Brazil. This study was conducted according to the STROBE checklist.

All participants read and signed an informed consent form, and data were collected after participants signed it.

This study included healthy people of both sexes who were aged over 50 years, who, during anamnesis, reported no history of unstable angina or myocardial infarction for less than three months and had no musculoskeletal, cardiorespiratory, neurological, or vascular changes that made it difficult to perform the tests.

Patients who had hemodynamic changes (systolic blood pressure higher than 140 or lower than 100 mmHg and a diastolic blood pressure higher than 100 and lower than 60 mmHg) before or after the tests, a resting heart rate higher than 120 bpm, or patients who did not complete the entire evaluation protocol due to withdrawal or clinical impossibility were excluded. Blood pressure was assessed at the time of testing.

Patients were recruited by disseminating this research in university environments by posters and social media posts. All patients underwent anamnesis. Pulmonary function was evaluated by spirometry; cardiorespiratory stress, by the incremental shuttle walking test (ISWT), six minute walk test (6MWT), and the stairs test (ST); mobility by the timed up and go test (TUGT); and balance by the Berg balance scale⁶ , ⁹ - ¹⁷.

The evaluations were performed on two days with an interval of at least 24 hours between them and always by the same examiner. On the first day, anamnesis, spirometry, Berg balance scale, and the six minute walk test were performed. On the second day, the timed up and go test, the stairs test, and the incremental shuttle walking test were carried out. The order of the tests aimed to reduce the effects of fatigue caused by each of them in the subsequent test.

In the anamnesis, patients were asked about comorbidities and smoking. Regarding smoking, they were asked about length (in years of consumption) and number of packs per day. Smoking load was calculated in pack-years.

Body mass (in kilograms) was measured on a digital scale (FILIZOLA^®) and height (in meters) by a stadiometer with centimeter-wide graduations. From these, the body mass index (BMI) was calculated by dividing volunteers’ mass by their height squared (m²).

Spirometry was performed according to the criteria of American THORACIC Society⁹ and the guidelines for pulmonary function testing¹⁰. After resting for five minutes, three tests of forced, reproductive, and acceptable vital capacity were performed. The values of forced vital capacity (FVC) and forced expiratory volume at the first second (FEV₁) were obtained in liters, the percentage of the prediction was based on the predicted normal values¹¹, and the FEV₁/ FVC ratio was calculated as a percentage.

All participants performed each test twice with a minimum interval of 10 minutes between them, the first for familiarization and the second for analysis.

Before and after each test, the respiratory rate (RR) was evaluated by counting the thoracic movements in one minute, whereas oxygen saturation (SpO₂) and pulse were measured by a portable pulse oximeter (MORIYA^® - Model 1005, São Paulo, Brazil) positioned on the second finger of patients’ dominant hand. Blood pressure (BP) was assessed by a cardiological stethoscope (LITTMANN, Minnesota, United States) and a sphygmomanometer (Aneróide Premium – G-Tech, Santa Catarina, Brazil) that was properly calibrated on the dominant arm. Moreover, the Borg scale¹² , ¹³ was explained and shown to participants, who were asked to grade their degree of dyspnea and the presence of pain in their lower limbs. The examiner waited for patients’ blood pressure to return to normal before applying each subsequent.

In the shuttle test, participants were instructed to walk in a 10-meter corridor limited by cones and with a speed determined by a sound signal recorded on electronic media, which increased by 0.17 m/s every minute, up to 15 stages. Patients were instructed to walk at a speed that would enable them to reach the cones at the time the sound signal sounded, and, at the end of each minute, an additional signal was given to alert them of the increase in speed¹⁴. The total distance was considered and compared to the predicted distance for this population¹⁵.

The end of the test was determined when patient’s distance from the cone was greater than 0.5 meters or if they reported chest pain, severe dyspnea, fatigue, and exhaustion or requested to stop.

The stairs test (ST) was performed on a shaded stair composed of four flights (46 steps), each step of which measured 0.16 m, totaling 7.36 meters of height and inclining by 30°. Patients were instructed to climb as fast as they could. Their climb time was recorded. The subjects climbed the stairs followed by a researcher who encouraged them with standardized phrases at each flight of the stairs. Patients’ time was compared to the predicted time¹⁶.

The 6MWT was performed in an open corridor under shade spanning 30 meters that was demarcated with tape every one meter and marked at the beginning and end by cones. Participants were instructed to walk as far as possible for six minutes, being able to stop or slow down if they deemed necessary. Verbal stimuli were standardized and performed by the examiner every minute, and the total distance was recorded and compared to the predicted distance¹⁷. The test would be discontinued if patients reported chest pain, severe dyspnea, fatigue and exhaustion or requested to stop¹⁸ , ¹⁹.

To assess functional mobility, participants were subjected to TUGT. To do so, they were placed in a 45-cm high chair in contact with the backrest and were instructed to get up and walk in a straight line for three meters at the highest possible speed without running, bypassing a cone at the three-meter mark and returning to the seat. The test was repeated three times and their time was recorded. Their best time was considered for evaluation⁶.

The Berg balance scale¹³ was adapted and validated in Brazil in 2012. It comprises a scale composed of 14 tasks related to daily life that involve static and dynamic balance. The items evaluated include patients’ ability to maintain positions of increasing difficulty, with a decrease in the support base for sitting up to a comfortable posture, standing with the feet together, and finally, in a tandem (that is, with one foot in front of the other) and single-leg postures, the two most difficult items. Other items assess how well patients can change positions (from sitting to standing) when moving from one chair to another, picking up an object from the floor, and sitting.

The completion of the tasks is evaluated by observation, the score of which ranges from zero to four in each task, totaling a maximum of 56 points, and the score is based on the time the position can be held, the distance patients’ arms can reach forward, or the time to complete a task. Therefore, these points are subtracted if patients fail to complete the distance on time, require supervision to execute of the task, rely on an external support, or receive help from the examiner.

For statistical analysis, SigmaStat^® was used. The sample was characterized by descriptive statistics and the data is shown as mean±standard deviation. The variables were analyzed by the Shapiro-Wilk normality test and had normal distribution. To verify a correlation between the static pulmonary function variables and the other variables of interest, the data were subjected to Pearson’s correlation test (p < 0.05).

RESULTS

This study included 55 people and excluded nine, thus assessing 46 (Figure 1).

Figure 1.
Flowchart: number of sample participants

Of the 46 that made up the sample, 37 (80.5%) were women and nine (19.5%) were men. Regarding smoking, 31 (67.40%) were former smokers, 13 (28.2%) current smokers, and two (4.4%) were nonsmokers. Concerning comorbidities, one (2.17%) individual reported respiratory problems; 33 (71.7%), heart problems, one (2.1%), neurological problems; and 11 (24%), other diseases (such as diabetes mellitus and renal failure). Table 1 shows other characteristics of the sample.

Table 1.
Characterization of the studied sample (shown as mean±standard deviation)

Parameter	Mean±SD
Age (years)	61.02±8.29
Weight (kg)	70.24±13.44
Height (m)	1.64±0.09
BMI (kg/m 2 )	26.60±5.00
Smoking load (pack-years)	43.31±3746

• kg=kilogram; m=meter; BMI=body mass index.

Regarding spirometric variables, 17 (37%) participants had an FVC lower than 80% of the predicted one, 24 (52.2%) had an FEV₁ below the predicted one, and 32 (69.6%) had an FEV₁/FVC below 80%. About FEF_25-75%, 29 (63%) people showed values below normality. In the ISWT result, only four participants (8.7%) had a higher result than predicted; in the 6MWT, only one (2.2%); and in the ST, seven (15.2%) (Table 2).

Table 2.
Spirometric and stress test variables (shown as mean±standard deviation)

Parameter	Mean±SD
FVC (l)	2.94±1.01
FVC (%)	86.20±19.01
FEV 1 (l)	2.16±0.88
FEV 1 (%)	79.57±22.65
FEV 1 /FVC (%)	73.74±12.32
FEF 25-75% (l/min)	2.16±0.95
FEF 25-75% (%)	77.40±34.26
ISWT (m)	337.88±115.58
ISWT (%)	66.63±21.47
6MWT (m)	446.41±111.29
6MWT (%)	74.91±17.85
ST (sec)	31.91±18.28
ST (%)	30.52±59.67

• FVC=forced vital capacity; FEF_25-75=forced expiratory flow from 25 to 75% FEV(1)=forced expiratory volume in the first second; L=liters; ISWT=incremental shuttle walk test; m=meters; 6MWT=six minute walk test; ST=stairs test.

Berg’s classification (BBS) showed 45 people with a score from 56 to 45 points (97.8%), so they had no risk of falling. Only one person had from 44 to 37 points (2.2%), that is, a slight risk of falling. The mean and standard deviation of BBS (points) totaled 53.54±3.23. TUGT data (in seconds) equaled 7.77±1.74.

Table 3 shows the correlation of static pulmonary function variables with the stress, mobility, and balance tests.

Table 3.
Correlation of static lung pulmonary variables with stress, mobility, and balance tests (r and p values)

	ISWT	ISWT (%)	6MWT	6MWT (%)	ST	ST (%)	TUGT	BBS
FVC (L)	0.36	0.75	0.51	0.24	−0.34	−0.58	−0.37	0.36
	0.02	0.01	0.01	0.11	0.02	0.01	0.01	0.02
FVC (%)	0.20	−0.04	0.35	0.17	−0.38	−0.24	−0.26	0.21
	0.18	0.80	0.02	0.26	0.01	0.12	0.08	0.16
FEV 1 (L)	0.31	−0.02	0.56	0.32	−0.40	−0.24	−0.34	0.40
	0.04	0.88	0.01	0.03	0.01	0.11	0.02	0.01
FEV 1 (%)	0.18	−0.01	0.48	0.33	−0.33	−0.21	−0.23	0.36
	0.24	0.93	0.01	0.03	0.03	0.16	0.12	0.01
FEV 1 /FVC	−0.03	−0.05	0.40	0.02	−0.27	−0.20	−0.13	0.34
	0.84	0.76	0.01	0.91	0.07	0.19	0.40	0.02
FEF 25-75 (%)	0.21	0.18	0.37	0.34	−0.22	−0.17	−0.12	0.21
	0.19	0.25	0.02	0.03	0.17	0.28	0.44	0.19
FEF 25-75	0.33	0.17	0.32	0.36	−0.23	−0.12	−0.14	0.24
	0.04	0.30	0.04	0.02	0.15	0.46	0.38	0.13

Associating the results of balance and mobility with those for the stress tests showed that TUGT had a moderate correlation with ISWT (0.41) and actual 6MWT (−0.43) and a weak correlation with ST (0.33). The BBS score showed a moderate correlation with ISWT (%) (−0.45), actual 6MWT (0.43), and actual (−0.59) and predicted (−0.45) ST and a weak correlation with predicted 6MWT (0.33) (Table 4).

Table 4.
Correlation of stress tests with mobility and balance tests (r and p values)

	ISWT	ISWT (%)	6MWT	6MWT (%)	ST	ST (%)
TUGT	0.41	−0.20	−0.43	−0.28	0.33	0.22
	0.01	0.19	0.01	0.06	0.02	0.15
BBS	0.22	−0.45	0.43	0.33	−0.59	−0.45
	0.15	0.01	0.01	0.03	0.01	0.01

ISWT=incremental shuttle walk test; 6MWT=six minute walk test; ST=stairs test; TUGT=timed up and go test; s=seconds; BBS=Berg balance scale.

DISCUSSION

This study found a statistical difference between some spirometric variables and the stress, mobility, and balance tests, but moderate or weak correlations. The stress tests also showed a moderate or weak correlation with the mobility and balance tests. Most participants in the sample were women; the higher occurrence of women is justified because the screening for research followed spontaneous demand. Women adhere more to treatment and health care plans. However, we believe this prevalence played no interference in the results since the used predictive formulas consider sex and were correlated with each other.

Most participants were former smokers, with a high average smoking load. Still, spirometric findings showed mild obstructions due to smoking. Smoking can alter pulmonary function, mainly decreasing expiratory flow and, in the long term, may lead to obstructive pulmonary disease that decreases oxygenation and consequently alters balance²⁰ , ²¹.

One third of participants showed restrictive alterations and the other two thirds, obstructive disorders in the spirometric evaluation. Moreover, 63% of participants had obstructions in small airways, as per a decrease in FEF _25-75% values. The age group of the sample, averaging 61 years, can justify these findings. According to the literature, aging leads to the loss of pulmonary elastic retraction, which justifies the reductions in expiratory flow. Furthermore, the loss of thoracic compliance and respiratory muscle strength explains the restrictive findings, and these changes may influence cardiorespiratory functional capacity³.

Regarding the Berg balance scale results, most of the sample showed no risk of falling¹³ , ²². Although the studied population already lived with ventilatory disorders, such disorders were not able to alter patients’ balance since they are mild. Patients with severe chronic obstructive pulmonary disease may show changed balance, mainly due to peripheral hypoxia²³.

Concerning mobility, participants showed no change in this aspect since they had TUGT values lower than 10 seconds. Considering that the sample in question has an average age above 60 years, the TUGT result could be considered normal up to 12 seconds²⁴.

Although balance and mobility lie within normal values, FVC and FEV₁ showed a correlation with the BBS and TUGT result, suggesting that the better the respiratory function, the better the balance and mobility. Those who have worse results in the TUGT suffer alterations during daily life activities²⁵. Thus, despite decreased pulmonary function in this sample, we can conclude that people would have no change in daily life activities.

Spirometric variables showed a relationship with stress tests, so that those with worse pulmonary function had worse results in the stress tests. The data from this study confirm those obtained from a study carried out with patients with chronic pulmonary disease, which showed that the degree of obstruction determines 6MWT outcome, and that the greater the obstruction, the lower the respiratory functional capacity²⁶. In this sample, people who showed reduced expiratory flow also had impaired cardiorespiratory capacity, possibly due to hyperinflation, which hinders ventilation and causes dyspnea²⁷.

The ST considers, in addition to cardiopulmonary capacity, the strength of lower limbs due to the need for muscle power to climb the flights of stairs in better time²⁸. In this study, the only spirometric variable that had no correlation with ST was FVC. This shows that other variables, such as muscle strength and metabolic capacity, may be more relevant in the result of this test.

In the analysis of the correlation of the stress tests with the mobility and balance tests, TUGT and BBS showed correlation with ISWT, 6MWT, and ST. In this study, participants showed independent locomotion and activities of daily living, which may explain their scores nearing maximum values.

The limitations of the study include its sample size and average age of participants (61 years) since the older, the age the greater the loss of muscle mass, balance, functional capacity, and pulmonary function. Another limitation is that this study ignored assessing patients’ level of physical activity. The practice of physical activity can influence physical and cardiorespiratory performance, as well as peripheral muscle strength.

This study has an important practical/clinical implication since the physiological changes of the aging process are known and begin around the age of 50 years. Patient care and physical therapy can improve it to prevent loss of muscle mass and pulmonary function.

CONCLUSION

Pulmonary function affects cardiorespiratory condition, mobility, and balance in people aged over 50 years. However, associating the results of balance and mobility with the stress tests showed a moderate or weak correlation.

This study aimed to evaluate the effect of static pulmonary function variables on cardiorespiratory condition, mobility, and balance in people aged over 50 years, as well as the effect of mobility and balance on three different stress tests in the same sample.

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• Financing source:
  nothing to declare
• Approved by the Research Ethics Committee under CAAE 1.861.176.

Publication Dates

• Publication in this collection
  04 Apr 2025
• Date of issue
  2025

History

• Received
  03 Apr 2022
• Accepted
  15 Jan 2024