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Cultural adaptation and validation of the Brazilian Portuguese version of the PROactive Physical Activity in COPD-clinical visit instrument for individuals with COPD

Adaptação cultural e validação da versão brasileira do instrumento PROactive Physical Activity in COPD-clinical visit para indivíduos com DPOC)

 
METHODS
 
Scoring and composition of domains
 
The PROactive Physical Activity in COPD-clinical visit (C-PPAC) is a self-reported instrument for hybrid evaluation of physical activity (PA) in daily life, that is, subjective assessment plus objective quantification. It consists of 12 questions addressing the PA performed in the last seven days and the difficulties in performing them. All of the questions are scored from zero to four, except for the first question whose score ranges from zero to three.
 
The first two questions compose the "amount of PA" domain, together with two separate self-report items (at the end of the instrument) which complement the items extracted from the PA assessment using PA monitors worn during the week preceding its administration. The other 10 items add up to compose the "difficulty in performing PA" domain.(1) Each domain score is based on the simple addition of items, and is then scaled from 0 to 100 following equivalences obtained in a Rasch model (Table S1). Finally, the "total score" is calculated by the sum of the two domains and divided by two. All scores range from 0 (worst) to 100 (best).

   
Cultural adaptation of the C-PPAC instrument for use in Brazil-panel of experts
 
Initially, the version developed by the research group from Portugal (already translated into Portuguese and in the process of validation in that country) was adapted for Brazilian Portuguese by a panel of five Brazilian experts. The experts were physiotherapists with a PhD in the area of Rehabilitation or Health Sciences, and all of them were familiar with the original versions of the PPAC instruments and had wide clinical or research experience with evaluating PA. The group also included a physiotherapist born in Portugal and currently working in Brazil who was consulted in the case of possible nuances found in the adaptation of the Portuguese-language version developed in Portugal.
 
Sample size calculation
 
Sample size calculation was performed by G*Power, version 3.1.9.7 (Heinrich Heine University, Düsseldorf, Germany). Assuming a correlation coefficient of at least 0.50 between the C-PPAC instrument and the main criterion instrument in this study (i.e., the International Physical Activity Questionnaire), considering an alpha error of 0.05 and a power (ß) of 0.80, the required sample size was initially calculated to be 13 individuals. Taking into account hypothetical losses of 10%, the minimum sample size was defined as 15 individuals. However, aiming at reducing bias, a larger sample was included.
 
Instruments
 
The short-form International Physical Activity Questionnaire(2) was used and it consists of three domains: walking, moderate PA, and vigorous PA. The questions are related to the activities performed during the week before the administration of the questionnaire. Participants can be classified according to the recommendations as sedentary, irregularly active, irregularly active A, irregularly active B, active, and very active. The modified Medical Research Council scale(3) is composed by five items among which the individual chooses how much dyspnea limits his/her functionality. The individual reports the subjective degree of limitation due to dyspnea in daily life by choosing one of the classifications ranging from 1 to 5, higher values corresponding to worse limitation. The modified version of the Saint George's Respiratory Questionnaire(4) is composed of questions about the recall of symptoms related to three months prior, distributed in three domains: symptoms, activity, and psychosocial impacts. The higher the final score is, the worse is the quality of life. Each domain has a maximum score; the points of each response are summed up and the total is referred to as a percentage of this maximum score. Values above 10% reflect hampered quality of life in each domain. The COPD Assessment Test(5) consists of eight domains with scores ranging from 0 to 5, adding up to a score between 0 and 40 points. According to the final score, the patient receives a classification regarding the impact of COPD on health status, higher values indicating a greater impact of the disease. Finally, the individuals wore the PA monitor ActiGraph, model wGT3X-BT (ActiGraph, Pensacola, FL, USA)(6) for 8 h/day (agreed time) for seven consecutive days between the first and second evaluations. The triaxial accelerometer measures the duration and intensity of PA. Participants were instructed to wear the device over their dominant hip using an elastic band for seven days. One day was considered valid if the participants used the device for at least 8 h/day. All were instructed to remove it for water-related activities, such as bathing or swimming, and also at bedtime. Only data from participants who used the accelerometer for at least four valid days were analyzed.  
REFERENCES
 
1.            Gimeno-Santos E, Raste Y, Demeyer H, Louvaris Z, de Jong C, Rabinovich RA, et al. The PROactive instruments to measure physical activity in patients with chronic obstructive pulmonary disease. Eur Respir J. 2015;46(4):988-1000. https://doi.org/10.1183/09031936.00183014
2.            Matsudo S, Araújo T, Matsudo V, Andrade D, Andrade E, Oliveira LC, et al. International physical activity questionnaire (IPAQ): study of validity and reliability in Brazil. Rev Bras Ativ Fis Saude. 2001;6(2):5-18.
3.            Kovelis D, Segretti NO, Probst VS, Lareau SC, Brunetto AF, Pitta F. Validation of the Modified Pulmonary Functional Status and Dyspnea Questionnaire and the Medical Research Council scale for use in Brazilian patients with chronic obstructive pulmonary disease. J Bras Pneumol. 2008;34(12):1008-1018. https://doi.org/10.1590/S1806-37132008001200005
4.            Camelier A, Rosa FW, Salim C, Nascimento OA, Cardoso F, Jardim JR. Using the Saint George's Respiratory Questionnaire to evaluate quality of life in patients with chronic obstructive pulmonary disease: validating a new version for use in Brazil. J Bras Pneumol. 2006;32(2):114-122. https://doi.org/10.1590/S1806-37132006000200006
5.            Silva GP, Morano MT, Viana CM, Magalhães CB, Pereira ED. Portuguese-language version of the COPD Assessment Test: validation for use in Brazil. J Bras Pneumol. 2013;39(4):402-408. https://doi.org/10.1590/S1806-37132013000400002
6.            Santos-Lozano A, Santin-Medeiros F, Cardon G, Torres-Luque G, Bailón R, Bergmeir C, et al. Actigraph GT3X: validation and determination of physical activity intensity cut points. Int J Sports Med. 2013;34(11):975-982. https://doi.org/10.1055/s-0033-1337945