Balance, falls, and risk of falls in COPD: systematic review of assessment instruments, measurement properties, and clinical utility

Lamezon, Ana Cristina; Cavon, Bruna Luna; Valderramas, Silvia

doi:10.1590/1981-22562024027.230189.en

Abstract

Objectives

to identify balance assessment instruments, issues and risks of issues used in COPD, evaluate their measurement properties, quality of evidence and clinical utility.

Method

A review was produced following the PRISMA and COSMIN guidelines, registered in PROSPERO: CRD42021235118. Searches were carried out from November 2021 to September 2022 in the PubMed, LILACS, CINAHL, Embase, Web of Science and PEDro databases. Cross-sectional and cohort observational studies were included, without restrictions on language or year of publication, as long as they described clinical instruments for assessing balance, falls and risk of falls reporting at least one of the measurement properties: validity, reliability and responsiveness. Two reviewers will independently apply the eligibility criteria, travel risk by COSMIN, quality of evidence by the GRADE approach and assessment of clinical utility by the Tyson and Connell Scale.

Results

9,102 studies were selected and 21 included in the review, nine studies demonstrated adequate and sufficient measurement properties and 12 instruments were identified, of which six were evaluated for the quality of evidence.

Conclusion

Systematic reviews of measurement properties require specialized reviewers and skills in qualitative analysis. With a recommendation GRADE of “A”, the Berg Balance Scale (BBS) and the Timed Up and Go (TUG) test were the most recommended instruments for COPD. By requiring the evaluation of the clinical utility of the result, the TUG demonstrates superiority to the BBS, proving to be a great tool for judging individuals who need a thorough assessment of balance, falls and risk of falls.

Keywords
Chronic Obstructive Pulmonary Disease; Balance; Falls; Risk of falls; Measurement properties

Resumo

Objetivos

Identificar os instrumentos de avaliação de equilíbrio, quedas e risco de quedas utilizados na DPOC, avaliar suas propriedades de medida, qualidade da evidência e utilidade clínica.

Método

A revisão foi produzida seguindo as orientações PRISMA e COSMIN, registrada no PROSPERO: CRD42021235118. As pesquisas foram realizadas de novembro de 2021 a setembro de 2022 nas bases de dados PubMed, LILACS, CINAHL, Embase, Web of Science e PEDro. Estudos observacionais transversais e coorte foram incluídos, sem restrição de idioma ou ano de publicação, desde que descreveram instrumentos clínicos de avaliação do equilíbrio, quedas e risco de quedas reportando no mínimo, uma das propriedades de medida: validade, confiabilidade e responsividade. Dois revisores independentemente aplicaram os critérios de elegibilidade, risco de viés pela COSMIN, qualidade da evidência pela abordagem GRADE e a avaliação da utilidade clínica pela Escala de Tyson e Connell.

Resultados

9.102 estudos foram selecionados e 21 incluídos na revisão, nove estudos demonstraram propriedades de medida adequadas e suficientes e 12 instrumentos foram identificados, dos quais seis, foram avaliados quanto a qualidade de evidência.

Conclusão

Revisões sistemáticas de propriedades de medida requerem revisores especializados e habilidade em análise qualitativa. Com grau de recomendação “A”, a Berg Balance Scale (BBS) e o teste Timed Up and Go (TUG) foram os instrumentos mais indicados na DPOC. Ao acrescentar a avaliação da utilidade clínica ao resultado, o TUG demonstra superioridade ao BBS, demostrando ser uma ótima ferramenta para triar indivíduos que necessitem de uma avaliação minuciosa do equilíbrio, quedas e risco de quedas.

Palavras-Chave:
Doença Pulmonar Obstrutiva Crônica; Equilíbrio; Quedas; Risco de Quedas; Propriedades de Medidas

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease, characterized by persistent respiratory symptoms and the presence of airflow limitation¹1 Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease 2022 Report; 2022 [acesso em 6 de novembro de2022].Disponível em : https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf

2 Agustí A, Celli BR, Criner GJ, Halpin D, Anzueto A, Barnes P, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. European Respiratory Journal [Internet]. 2023 [acesso em 1 de março de 2023]; 1;61(4):2300239. Disponível em: https://erj.ersjournals.com/content/61/4/2300239

3 Celli B, Fabbri L, Criner G, Martinez FJ, Mannino D, Vogelmeier C, et al. Definition and Nomenclature of Chronic Obstructive Pulmonary Disease: Time for Its Revision. American Journal of Respiratory and Critical Care Medicine [Internet]. 2022. [acesso em 10 de fevereiro de 2023]; 1;206(11):1317–25. Disponível em: https://doi.org/10.1164/rccm.202204-0671PP
https://doi.org/10.1164/rccm.202204-0671... -⁴4 Kovelis D, Gomes ARS, Mazzarin C, Biazim SK, Pitta F, Valderramas S. Effectiveness and Safety of Supervised Home-Based Physical Training in Patients With COPD on Long-term Home Oxygen Therapy: A Randomized Trial. Chest. [Internet]. 2020; 158(3): 965-72. Disponível em: https://doi.org/10.1016/j.chest.2020.02.063
https://doi.org/10.1016/j.chest.2020.02.... . The impairment of COPD is not limited to respiratory function⁴4 Kovelis D, Gomes ARS, Mazzarin C, Biazim SK, Pitta F, Valderramas S. Effectiveness and Safety of Supervised Home-Based Physical Training in Patients With COPD on Long-term Home Oxygen Therapy: A Randomized Trial. Chest. [Internet]. 2020; 158(3): 965-72. Disponível em: https://doi.org/10.1016/j.chest.2020.02.063
https://doi.org/10.1016/j.chest.2020.02.... ,⁵5 Mazzarin CM, Silveira BR, Lamezon AC, Cavon Luna B, Valderramas S. Effectiveness and Safety of Multicomponent Physical Training in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial. Health Services Insights [Internet]. 2023; 16. Disponível em: https://doi.org/10.1177/11786329231169255
https://doi.org/10.1177/1178632923116925... . People with COPD have impaired postural control when compared to healthy individuals in the same age group⁵5 Mazzarin CM, Silveira BR, Lamezon AC, Cavon Luna B, Valderramas S. Effectiveness and Safety of Multicomponent Physical Training in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial. Health Services Insights [Internet]. 2023; 16. Disponível em: https://doi.org/10.1177/11786329231169255
https://doi.org/10.1177/1178632923116925...

6 Scremim CF, Simões B, de Barros JA, Valderramas S. Construct validity and reliability of the Brazilian version of the Falls Efficacy Scale in patients with COPD. Pulmonology[Internet]. 2020;26(5):268-74.Disponível em: https://doi.org/10.1016/j.pulmoe.2020.01.008
https://doi.org/10.1016/j.pulmoe.2020.01... -⁷7 Butcher SJ, Meshke JM, Sheppard MS. Reductions in Functional Balance, Coordination, and Mobility Measures Among Patients With Stable Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation[Internet]. 2004;24(4):274–80. Disponível em: https://doi.org/10.1097/00008483-200407000-00013
https://doi.org/10.1097/00008483-2004070... . Deficits in function and mobility have been associated with a greater risk of falls in older adults⁷7 Butcher SJ, Meshke JM, Sheppard MS. Reductions in Functional Balance, Coordination, and Mobility Measures Among Patients With Stable Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation[Internet]. 2004;24(4):274–80. Disponível em: https://doi.org/10.1097/00008483-200407000-00013
https://doi.org/10.1097/00008483-2004070... and have a negative impact on quality of life⁸8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311
https://doi.org/10.1177/1479973118820311...

9 Beauchamp MK, Hill K, Goldstein RS, Janaudis-Ferreira T, Brooks D. Impairments in balance discriminate fallers from non-fallers in COPD. Respiratory medicine [Internet]. 2009;103(12):1885-91. Disponível em: https://doi.org/10.1016/j.rmed.2009.06.008
https://doi.org/10.1016/j.rmed.2009.06.0... -¹⁰10 Lu H, Dong XX, Li DL, Wu Q, Nie XY, Xu Y, et al. Prevalent falls, fall frequencies and health-related quality of life among community-dwelling older Chinese adults. Quality of Life Research[Internet]. 2023;32(11):3279–89. Disponível em: https://doi.org/10.1007/s11136-023-03474-2
https://doi.org/10.1007/s11136-023-03474... .

Studies suggest that COPD is one of the chronic diseases with the highest prevalence of falls¹1 Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease 2022 Report; 2022 [acesso em 6 de novembro de2022].Disponível em : https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf,⁵5 Mazzarin CM, Silveira BR, Lamezon AC, Cavon Luna B, Valderramas S. Effectiveness and Safety of Multicomponent Physical Training in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial. Health Services Insights [Internet]. 2023; 16. Disponível em: https://doi.org/10.1177/11786329231169255
https://doi.org/10.1177/1178632923116925... ,⁶6 Scremim CF, Simões B, de Barros JA, Valderramas S. Construct validity and reliability of the Brazilian version of the Falls Efficacy Scale in patients with COPD. Pulmonology[Internet]. 2020;26(5):268-74.Disponível em: https://doi.org/10.1016/j.pulmoe.2020.01.008
https://doi.org/10.1016/j.pulmoe.2020.01... . In a study with a sample of 4,050 women, aged between 60 and 79 years, the prevalence of falls increased with the number of chronic diseases. The population attributable risk of having suffered at least one fall in the last 12 months estimated by adjustable models was 17.4% (10.4% to 23.9%) for arthritis, 9.4% (5.4% to 13.3%) for depression, 8% (3.3% to 12.4%) for COPD, 6.2% (1.6% to 10.5%) for circulatory diseases and 6.2% (2% to 10%) for coronary heart disease¹¹11 Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ[Internet]. 2003;327(7417):712-7.Disponível em: https://doi.org/10.1136/bmj.327.7417.712
https://doi.org/10.1136/bmj.327.7417.712... . Falls are associated not only with mortality and morbidity, but also with loss of autonomy⁵5 Mazzarin CM, Silveira BR, Lamezon AC, Cavon Luna B, Valderramas S. Effectiveness and Safety of Multicomponent Physical Training in Patients With Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Clinical Trial. Health Services Insights [Internet]. 2023; 16. Disponível em: https://doi.org/10.1177/11786329231169255
https://doi.org/10.1177/1178632923116925... ,⁶6 Scremim CF, Simões B, de Barros JA, Valderramas S. Construct validity and reliability of the Brazilian version of the Falls Efficacy Scale in patients with COPD. Pulmonology[Internet]. 2020;26(5):268-74.Disponível em: https://doi.org/10.1016/j.pulmoe.2020.01.008
https://doi.org/10.1016/j.pulmoe.2020.01... ,⁸8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311
https://doi.org/10.1177/1479973118820311... . Physiological mechanisms, such as changes in muscle strength, proprioception, body sway and compromised balance, may be associated with a greater risk of falls in COPD and contribute to worsening health conditions⁷7 Butcher SJ, Meshke JM, Sheppard MS. Reductions in Functional Balance, Coordination, and Mobility Measures Among Patients With Stable Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation[Internet]. 2004;24(4):274–80. Disponível em: https://doi.org/10.1097/00008483-200407000-00013
https://doi.org/10.1097/00008483-2004070...

8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311
https://doi.org/10.1177/1479973118820311...

9 Beauchamp MK, Hill K, Goldstein RS, Janaudis-Ferreira T, Brooks D. Impairments in balance discriminate fallers from non-fallers in COPD. Respiratory medicine [Internet]. 2009;103(12):1885-91. Disponível em: https://doi.org/10.1016/j.rmed.2009.06.008
https://doi.org/10.1016/j.rmed.2009.06.0...

10 Lu H, Dong XX, Li DL, Wu Q, Nie XY, Xu Y, et al. Prevalent falls, fall frequencies and health-related quality of life among community-dwelling older Chinese adults. Quality of Life Research[Internet]. 2023;32(11):3279–89. Disponível em: https://doi.org/10.1007/s11136-023-03474-2
https://doi.org/10.1007/s11136-023-03474...

11 Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ[Internet]. 2003;327(7417):712-7.Disponível em: https://doi.org/10.1136/bmj.327.7417.712
https://doi.org/10.1136/bmj.327.7417.712...

12 Pérez-Ros P, Martínez-Arnau FM, Tarazona-Santabalbina FJ. Risk Factors and Number of Falls as Determinants of Quality of Life of Community-Dwelling Older Adults. Journal of Geriatric Physical Therapy[Internet]. 2019;42(2):63-72.Disponível em: https://doi.org/10.1519/jpt.0000000000000150
https://doi.org/10.1519/jpt.000000000000... -¹³13 Almeida CNS, Costa RA da, Manso KP, Ferreira JF, Callegari B, Oliveira CC, et al. Static balance in older adults with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation. Geriatrics, Gerontology and Aging[Internet]. 2020;14(2):98–107. Disponível em: https://doi.org/10.5327/z2447-212320201900091
https://doi.org/10.5327/z2447-2123202019... . Research has highlighted the importance of identifying risk factors for falls and promoting prevention¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022
https://doi.org/10.1016/j.rmed.2009.03.0... , ¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-... . For prevention to be effective, it is necessary to identify the population at risk, introduce standardized and reliable assessment measures, and then establish specific multidimensional interventions focused on reducing the identified modifiable risk factors¹⁰10 Lu H, Dong XX, Li DL, Wu Q, Nie XY, Xu Y, et al. Prevalent falls, fall frequencies and health-related quality of life among community-dwelling older Chinese adults. Quality of Life Research[Internet]. 2023;32(11):3279–89. Disponível em: https://doi.org/10.1007/s11136-023-03474-2
https://doi.org/10.1007/s11136-023-03474... , ¹³13 Almeida CNS, Costa RA da, Manso KP, Ferreira JF, Callegari B, Oliveira CC, et al. Static balance in older adults with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation. Geriatrics, Gerontology and Aging[Internet]. 2020;14(2):98–107. Disponível em: https://doi.org/10.5327/z2447-212320201900091
https://doi.org/10.5327/z2447-2123202019... ,¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022
https://doi.org/10.1016/j.rmed.2009.03.0... .

The instruments for assessing balance, falls and risk of falls when applied to COPD allow professionals to identify and quantify possible deficits found in balance, the presence of falls and the risk of a fall occurring. Such instruments allow monitoring of these changes and favor appropriate clinical decision-making aimed at better intervention. Instruments must be valid, reliable and responsive, otherwise there is a risk of obtaining results that could lead to erroneous conclusions and conduct⁶6 Scremim CF, Simões B, de Barros JA, Valderramas S. Construct validity and reliability of the Brazilian version of the Falls Efficacy Scale in patients with COPD. Pulmonology[Internet]. 2020;26(5):268-74.Disponível em: https://doi.org/10.1016/j.pulmoe.2020.01.008
https://doi.org/10.1016/j.pulmoe.2020.01... , ¹⁶16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179... ,¹⁷17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822... .

Systematic reviews of outcome measurement instruments are important tools for selecting the most appropriate instrument for the construct of interest and providing an overview of quality through measurement properties¹⁶16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179...

17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822...

18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886...

19 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
https://doi.org/10.1177/0269215519877498... -²⁰20 Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
https://doi.org/10.1177/0269215509339004... . Therefore, it is important to determine whether the available assessment instruments capture all dimensions related to the construct. A better understanding of measurement properties will help professionals select the most appropriate instruments to use in their clinical practice.

A wide variety of instruments to measure balance, falls, and fall risk can be used in COPD. Our objective was to identify instruments for assessing balance, falls and risk of falls used in COPD, evaluate their measurement properties, quality of evidence and clinical utility.

METHOD

This systematic review complies with PRISMA and COSMIN guidance for systematic reviews of outcome measurement instruments and the protocol has been registered with PROSPERO: CRD42021235118. This review included cross-sectional observational and cohort studies of adults aged 50 years or over, diagnosed with COPD, in accordance with international guidelines¹1 Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease 2022 Report; 2022 [acesso em 6 de novembro de2022].Disponível em : https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf,³3 Celli B, Fabbri L, Criner G, Martinez FJ, Mannino D, Vogelmeier C, et al. Definition and Nomenclature of Chronic Obstructive Pulmonary Disease: Time for Its Revision. American Journal of Respiratory and Critical Care Medicine [Internet]. 2022. [acesso em 10 de fevereiro de 2023]; 1;206(11):1317–25. Disponível em: https://doi.org/10.1164/rccm.202204-0671PP
https://doi.org/10.1164/rccm.202204-0671... , regardless of gender or level of disability. Studies that reported balance, falls and risk of falls instruments including tests, scales or questionnaires, methodological studies that developed the instruments and/or evaluated their measurement properties reporting the evaluation of at least one of the following measurement properties were eligible: validity, reliability and responsiveness. Case studies and series reports, study protocols, clinical trials and studies not available in their entirety were excluded. Classifications were agreed upon by consensus among the review team to reduce variability in interpretation.

An extensive literary search was carried out in electronic databases from November 2021 to September 2022 in the PubMed, LILACS, CINAHL, Embase, Web of Science and PEDro databases. The search did not restrict language or year of publication. The search strategy was carried out for each database, including controlled database vocabulary when available (MeSH, EMTREE and CINAHL Subjective Headings) and free terms with the combination of the words “Chronic Obstructive Pulmonary Disease”, “balance”, “falls”, “risk of falls”. Then the words “measurement properties”, “reliability”, “validity” and “reproducibility” were added with the purpose of increasing the sensitivity of the research and adapting it to the COSMIN methodology.

Two reviewers (A.L. and B.L.) independently applied the eligibility criteria for the selection of studies, such as study objectives, population characteristics, clinical measure evaluated, measurement instruments, examiners, operationalization of measures and type of statistical analysis. Another reviewer (S.V.) was requested in case of disagreement or doubt. All collected data was allocated to the Mendelay reference management program and reference analysis was performed manually. After removal of duplicates, reviewers (A.L. and B.L.) independently screened titles and abstracts followed by full-text screening in a blinded manner using standardized electronic forms. Disagreements were resolved by consensus.

Two researchers independently (A.L. and B.L.) analyzed the quality of the included studies through the Consensus-based in COSMIN Risk of Bias tool to assess the quality of studies on reliability and measurement error of outcome measurement instrument ¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-...

16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179...

17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822...

18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886... -¹⁹19 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
https://doi.org/10.1177/0269215519877498... . The COSMIN Risk of Bios tool tracks the risk of bias of the individual studies included and describes the elements that together assist us in constructing a research question and provides a comprehensive overview of the components of the outcome measure as well as the design requirements and preferred statistical methods regarding instrument measurement reliability and error.

The classification of instrument evidence was performed using the GRADE approach modified by COSMIN.

Two independent researchers (A. L. and B. L.) evaluated the clinical utility of the measurement instruments found in the systematic review using the Tyson and Connell clinical utility scale²⁰20 Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
https://doi.org/10.1177/0269215509339004... which evaluates four items: instrument application time, data analysis and interpretation, cost, need for equipment and specific training, and portability. The final score quantifies whether a specific instrument can be used and recommended for clinical practice. For the instrument to be recommended, it must have a score greater than or equal to nine.

DATA AVAILABILITY

The entire dataset supporting the results of this study is available upon request from the corresponding author [Ana Cristina Lamezon]

RESULTS

The search strategy identified 9,102 studies. The results of the database search and the selection process are detailed in Figure 1. Of this total, 21 studies met the eligibility criteria and were included in this systematic review and 12 instruments for assessing balance, falls and risk of falling were found. Participant characteristics in the included studies are summarized in Table 1.

Figure 1
Flowchart of study selection according to the Preferred Reporting Items for systematic Reviews and MetaAnalyses. Curitiba, PR, Brazil, 2023.

Thumbnail

Table 1
Characteristics of the studies included in the Systematic Review. Curitiba, PR, Brazil,2023.

The instruments for assessing balance, falls and risk of falls found in this review were categorized into performance instruments (PerFORM): Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), MINI-BESTest, Brief-BESTest, Timed up and Go (TUG), Timed up and Go dual task (TUGDT), Single-Leg Stance (SLS), Tinetti get up and go test, Unipodal Stance Test (UST); Instruments with results reported by the evaluator, (ClinROM): Force platform or posturography; Self-report questionnaires (PROM): self-report of falls and the Elderly Falls Screening Test (EFST).

The risk of bias of the included studies according to COSMIN Risk of Bias checklist ⁹9 Beauchamp MK, Hill K, Goldstein RS, Janaudis-Ferreira T, Brooks D. Impairments in balance discriminate fallers from non-fallers in COPD. Respiratory medicine [Internet]. 2009;103(12):1885-91. Disponível em: https://doi.org/10.1016/j.rmed.2009.06.008
https://doi.org/10.1016/j.rmed.2009.06.0...

10 Lu H, Dong XX, Li DL, Wu Q, Nie XY, Xu Y, et al. Prevalent falls, fall frequencies and health-related quality of life among community-dwelling older Chinese adults. Quality of Life Research[Internet]. 2023;32(11):3279–89. Disponível em: https://doi.org/10.1007/s11136-023-03474-2
https://doi.org/10.1007/s11136-023-03474...

11 Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ[Internet]. 2003;327(7417):712-7.Disponível em: https://doi.org/10.1136/bmj.327.7417.712
https://doi.org/10.1136/bmj.327.7417.712... -¹²12 Pérez-Ros P, Martínez-Arnau FM, Tarazona-Santabalbina FJ. Risk Factors and Number of Falls as Determinants of Quality of Life of Community-Dwelling Older Adults. Journal of Geriatric Physical Therapy[Internet]. 2019;42(2):63-72.Disponível em: https://doi.org/10.1519/jpt.0000000000000150
https://doi.org/10.1519/jpt.000000000000... is presented in Table 2. The main measurement properties evaluated were reliability, internal consistency and construct validity. Criterion validity was demonstrated only in one study where the abbreviated MiniBESTest instrument was validated from BESTest. Of the 21 studies included, nine presented measurement properties considered adequate and sufficient, five adequate and insufficient, one adequate and indeterminate, four studies were classified as doubtful and insufficient and one study classified as doubtful and indeterminate following the COSMIN methodology.

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Table 2
Risk of bias according to COSMIN Risk of Bias Checklist. Curitiba, PR, Brazil, 2023.

After consensus among the authors, we chose to analyze only the assessment instruments of the included studies that presented adequate and sufficient measurement properties. The reliability domain was the most addressed in these studies (five studies) and the quality of the evidence in these instruments was determined through the modified GRADE approach and characterized by the level of evidence in A, B or C. Instruments classified as “A” have sufficient evidence to recommend their use in COPD, “B” are not recommended and “C” require further studies for recommendation and are presented in Table 3.

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Table 3
. Quality of evidence according to modified GRADE. PR, Brazil, 2023

The BBS and TUG instruments presented an “A” rating for quality of evidence, and are recommended for assessing balance and risk of falls in COPD. The BESTest, MiniBESTest, BriefBEST-test and UST instruments were classified as moderate “C” evidence and require further studies for recommendation. None of the instruments included in this review with measurement properties classified as adequate and sufficient were classified as “B”.

The Tyson and Connell Scale²⁰20 Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
https://doi.org/10.1177/0269215509339004... was applied to instruments that presented adequate and sufficient measurement properties according to the risk of bias and quality of evidence. We observed that most instruments obtained the maximum score (9/10 or 10/10) in the assessment of clinical utility, as can be seen in Table 4.

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Table 4
. Clinical utility of measuring instruments. Curitiba, PR, Brasil, 2023.

DISCUSSION

This systematic review was designed to determine the most appropriate balance, falls and fall risk assessment instruments for use in COPD and provide a comprehensive view of the properties of measurements found in the literature and provide support for recommendation in clinical practice with sufficient evidence.

The selection of included instruments was based on evidence of the quality of the outcome of these measurement instruments (i.e. reliability, validity and responsiveness) as well as aspects of feasibility or clinical utility following the COSMIN initiative criteria and clinical utility scale by Tyson and Connell²⁰20 Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
https://doi.org/10.1177/0269215509339004... . We identified the following balance, falls and risk of falls instruments used in COPD: (1) BBS - assesses functional balance and risk of falls; (2) BESTest, MiniBESTest and BriefBESTest - static and dynamic balance; (3) TUG and TUGDT - functional mobility and risk of falls, (4) SLS, Tinette Test, UST and posturography, assessment of static balance, (5) EFST and Self-report of falls - assessment of retrospective falls. Of the 12 instruments found, only six presented sufficient quality of evidence for some degree of recommendation in COPD. The quality of evidence was assessed only in instruments included in studies with at least adequate quality in the development of the study and sufficient reliability assessment¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-... ,¹⁶16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179... .

Every instrument must reflect the internal structure of the construct, that is, the empirical structure of the instrument must reflect the theoretical structure that must be covered by the measure. The assessment of the internal structure, which comprises structural validity, internal consistency, cultural validity, will only be relevant if the instrument is composed of multiple items and based on a reflective model, which assumes that all items of a scale or subscale are manifestations of an underlying construct¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022
https://doi.org/10.1016/j.rmed.2009.03.0...

15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-...

16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179...

17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822...

18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886... -¹⁹19 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
https://doi.org/10.1177/0269215519877498... .

Regarding cross-cultural validity, although many original versions have been translated into other languages or adapted to other cultures, we identified only three studies that cited validations²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391
https://doi.org/10.2522/ptj.20150391... , ³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609
https://doi.org/10.3390/jcm9020609... ,³⁵35 Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427
https://doi.org/10.1097/HCR.000000000000... , that is, they did not evaluate such a measure and only in one study the property was evaluated and it was classified as adequate³⁵35 Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427
https://doi.org/10.1097/HCR.000000000000... . Such studies are necessary to assess whether measurements from a population of a given culture are equivalent to those from another population.

The most frequently found measurement property, and for which the instruments showed sufficient evidence, was the hypothesis test for construct validity, where only four studies presented doubtful classification. Authors often use the term criterion validity for studies in which an instrument is compared to others that measure a similar construct. In most cases, this would be considered evidence for construct validity, rather than criterion validity following the considerations of the COSMIN methodology. Its definitions and analyzes must be demonstrated in hypothesis testing for construct validity¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-...

16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179...

17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822...

18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886... -¹⁹19 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
https://doi.org/10.1177/0269215519877498... .

Criterion validity is the degree to which an instrument's scores are a reflection of a “gold standard”¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-...

16 Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
https://doi.org/10.1186/s12874-020-01179...

17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822... -¹⁸18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886... . Based on the COSMIN guidelines, we agree that there is no gold standard for the identified instruments¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-... ,¹⁷17 Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
https://doi.org/10.1007/s11136-021-02822... ,¹⁸18 Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
https://doi.org/10.2147/prom.s398886... , unless the instrument has a long and a short form. In this case, the full version of a measure is the “gold standard” of the short form¹¹11 Lawlor DA, Patel R, Ebrahim S. Association between falls in elderly women and chronic diseases and drug use: cross sectional study. BMJ[Internet]. 2003;327(7417):712-7.Disponível em: https://doi.org/10.1136/bmj.327.7417.712
https://doi.org/10.1136/bmj.327.7417.712... . In our study, criterion validity was only scored in the MiniBEST and BriefBESTest instruments, which are summarized versions of BESTest²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391
https://doi.org/10.2522/ptj.20150391... ,³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240
https://doi.org/10.1097/HCR.000000000000... .

The reliability domain through test-retest was evaluated in seven studies with adequate and sufficient measures²²22 Crişan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD. PloS one [Internet]. 2015;10(3): e0120573. Disponível em: https://doi.org/10.1371/journal.pone.0120573
https://doi.org/10.1371/journal.pone.012... ,²⁷27 Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207
https://doi.org/10.1177/2150131915577207... ,²⁸28 Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752
https://doi.org/10.3390/jcm8101752... ,³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609
https://doi.org/10.3390/jcm9020609... ,³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240
https://doi.org/10.1097/HCR.000000000000... . The measurement error was reported in only two studies and with insufficient data for an adequate classification²²22 Crişan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD. PloS one [Internet]. 2015;10(3): e0120573. Disponível em: https://doi.org/10.1371/journal.pone.0120573
https://doi.org/10.1371/journal.pone.012... ,³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609
https://doi.org/10.3390/jcm9020609... .

We identified that the BBS and TUG were the most appropriate instruments for COPD, with a recommendation grade of “A”, but in the clinical utility criterion²⁰20 Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
https://doi.org/10.1177/0269215509339004... the TUG stood out due to the shorter application time compared to the BBS, which proves to be useful for screening patients who will require a more in-depth balance assessment¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022
https://doi.org/10.1016/j.rmed.2009.03.0... ,¹⁹19 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
https://doi.org/10.1177/0269215519877498... . With recommendation grade B, the BESTest, MiniBESTest, BriefBESTest and UST instruments can be provisionally recommended until new studies are developed, mainly because in the studies found with adequate and sufficient evidence the number of participants was below 100, which according to the Modified GRADE¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4
https://doi.org/10.1007/s11136-017-1765-... evaluation is enough to downgrade the evidence.

Broad, comprehensive and sensitive database research and the use of rigorous methodology are aspects to be highlighted in this review. The studies were independently reviewed, as recommended by COSMIN's best evidence, in accordance with the Cochrane methodology. Classifications were agreed upon by consensus among the review team to reduce variability in interpretation.

As an eligibility criterion, our study sought individuals diagnosed with COPD aged 50 years or older. Most of the included studies fully met this criterion, but in the study by Singh et al³⁴34 Singh SS, Bhat A, Mohapatra AK, Manu MK, Vaishali K. Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants. Heart & Lung[Internet]. 2019; Disponível em: https://doi.org/10.1016/j.hrtlng.2019.09.006
https://doi.org/10.1016/j.hrtlng.2019.09... part of the recruited sample was aged over 40 years. It is possible that in a younger population with COPD, the recommendations of this study cannot be extrapolated.

As there are currently no standards and criteria for content validity, face validity, which is a very subjective judgment about whether the content of the instrument really appears to be an adequate reflection of the construct being measured, the evaluation of this criterion by reviewers may suffer from interpretation bias.

As no instrument was developed for COPD specifically, content validity was assumed and classified as adequate, since during the validation process for other diseases the instrument was analyzed and presents relevant, comprehensive and understandable items with regard to the construct of interest. It would be interesting that in future validation studies of measurement instruments for COPD, content validity is carried out for this specific population.

CONCLUSION

Systematic reviews of measurement properties are complex and involve reviewers with knowledge of the construct of interest, experience in the target population, and expertise in measurement properties and qualitative analysis. Researchers and professionals who are deciding on the most appropriate balance, falls, and fall risk measurement instrument for use in COPD can often find multiple instrument models, and the recommendations noted in this systematic review can assist in making the most appropriate clinical decision about the use of these instruments.

BBS and TUG were the instruments with the highest degree of recommendation for application in COPD, but in the clinical utility criterion, the TUG stood out due to the shorter application time.

This review identifies gaps in the presence of quality evidence in available measurement instruments and therefore provides a useful framework both for further evaluations of these instruments and for the development of new specific instruments to assess balance, falls and risk of falls in COPD. The results of this review will also help researchers and healthcare professionals make evidence-based decisions about the use of these measurement instruments.

There was no funding for the execution of this work.

Data availability statement

DATA AVAILABILITY

The entire dataset supporting the results of this study is available upon request from the corresponding author [Ana Cristina Lamezon]

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» https://doi.org/10.1007/s11136-017-1765-4
¹⁶
Mokkink LB, Boers M, van der Vleuten CPM, Bouter LM, Alonso J, Patrick DL, et al. COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology[Internet]. 2020;Disponível em: https://doi.org/10.1186/s12874-020-01179-5
» https://doi.org/10.1186/s12874-020-01179-5
¹⁷
Gagnier JJ, Lai J, Mokkink LB, Terwee CB. COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021;30(8):2197–218. Disponível em: https://doi.org/10.1007/s11136-021-02822-4
» https://doi.org/10.1007/s11136-021-02822-4
¹⁸
Mokkink LB, Eekhout I, Boers M, van, de C. Studies on Reliability and Measurement Error of Measurements in Medicine – From Design to Statistics Explained for Medical Researchers[Internet]. 2023; 14: 193–212. Disponível em: https://doi.org/10.2147/prom.s398886
» https://doi.org/10.2147/prom.s398886
¹⁹
Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson’s disease: a systematic review of psychometric properties. Clinical Rehabilitation[Internet]. 2019;33(12):1949–62. Disponível em: https://doi.org/10.1177/0269215519877498
» https://doi.org/10.1177/0269215519877498
²⁰
Tyson S, Connell L. The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review. Clinical Rehabilitation[Internet]. 2009;23(11):1018–33. Disponível em: https://doi.org/10.1177/0269215509339004
» https://doi.org/10.1177/0269215509339004
²¹
McLay R, Kirkwood RN, Kuspinar A, Richardson J, Wald J, Raghavan N, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chronic Respiratory Disease[Internet]. 2020;17. Disponível em: https://doi.org/10.1177/1479973120922538
» https://doi.org/10.1177/1479973120922538
²²
Crişan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD. PloS one [Internet]. 2015;10(3): e0120573. Disponível em: https://doi.org/10.1371/journal.pone.0120573
» https://doi.org/10.1371/journal.pone.0120573
²³
Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391
» https://doi.org/10.2522/ptj.20150391
²⁴
Oliveira CC, McGinley J, Lee AL, Irving LB, Denehy L. Fear of falling in people with chronic obstructive pulmonary disease. Respir Med[Internet]. 2015;109(4):483-9. Disponível em: https://doi.org/10.1016/j.rmed.2015.02.003
» https://doi.org/10.1016/j.rmed.2015.02.003
²⁵
Ozalevli S, Ilgin D, Narin S, Akkoclu A. Association between disease-related factors and balance and falls among the elderly with COPD: a cross-sectional study. Aging Clinical and Experimental Research[Internet]. 2011;23(5-6):372–7.Disponível em: https://doi.org/10.1007/bf03325235
» https://doi.org/10.1007/bf03325235
²⁶
Voica A ,Oancea C, Tudorache E, Crisan A, Fira-Mladinescu O, Tudorache V, et al. Chronic obstructive pulmonary disease phenotypes and balance impairment. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2016; 11(1):919-925. Disponível em: https://doi.org/10.2147/COPD.S101128
» https://doi.org/10.2147/COPD.S101128
²⁷
Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207
» https://doi.org/10.1177/2150131915577207
²⁸
Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752
» https://doi.org/10.3390/jcm8101752
²⁹
Porto EF, Pradella CO, Rocco CM, Chueiro M, Jr., Maia RQ, Ganança FF, et al. Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2017;37(2):139–45. Disponível em: https://doi.org/10.1097/HCR.0000000000000246
» https://doi.org/10.1097/HCR.0000000000000246
³⁰
Hellström K, Vahlberg B, Urell C, Emtner M. Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease. Clinical Rehabilitation[Internet]. 2009;23(12):1136–44. Disponível em: https://doi.org/10.1177/0269215509342329
» https://doi.org/10.1177/0269215509342329
³¹
Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609
» https://doi.org/10.3390/jcm9020609
³²
Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240
» https://doi.org/10.1097/HCR.0000000000000240
³³
Al Haddad MA, John M, Hussain S, Bolton CE. Role of the Timed Up and Go Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention[Internet]. 2016;36(1):49–55. Disponível em: https://doi.org/10.1097/hcr.0000000000000143
» https://doi.org/10.1097/hcr.0000000000000143
³⁴
Singh SS, Bhat A, Mohapatra AK, Manu MK, Vaishali K. Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants. Heart & Lung[Internet]. 2019; Disponível em: https://doi.org/10.1016/j.hrtlng.2019.09.006
» https://doi.org/10.1016/j.hrtlng.2019.09.006
³⁵
Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427
» https://doi.org/10.1097/HCR.0000000000000427
³⁶
Harrison SL, Beauchamp MK, Sibley K, Araujo T, Romano J, Goldstein RS, et al. Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease. BMC Pulmonary Medicine[Internet]. 2015;15(1).Disponível em: https://doi.org/10.1186/s12890-015-0067-2
» https://doi.org/10.1186/s12890-015-0067-2
³⁷
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 [Internet]. 2011;105(3):461–9. Disponível em: https://doi.org/10.1016/j.rmed.2010.08.015
» https://doi.org/10.1016/j.rmed.2010.08.015
³⁸
Tudorache E, Oancea C, Avram C, Fira-Mladinescu O, Petrescu L, Timar B. Balance impairment and systemic inflammation in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2015; 10(1):1847-1852. Disponível em: https://doi.org/10.2147/copd.s89814
» https://doi.org/10.2147/copd.s89814
³⁹
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 With Healthy Controls and Differences According to Sex and Disease Severity. Respiratory care [Internet]. 2016;61(11):1488–96. Disponível em: https://doi.org/10.4187/respcare.04749
» https://doi.org/10.4187/respcare.04749

Edited by

Edited by: Marquiony Marques dos Santos

Data availability

The entire dataset supporting the results of this study is available upon request from the corresponding author [Ana Cristina Lamezon]

Publication Dates

Publication in this collection
11 Mar 2024
Date of issue
2024

History

Received
31 July 2023
Accepted
22 Dec 2023

The entire content of the journal, except where indicated, is licensed under an attribution CC-BY type Creative Commons License

[1] There was no funding for the execution of this work.

Studies	COPD (n)	M (n)	F (n)	COPD Sta (n)	COPD Exa (n)	Contr (n)	Age (years)	Smo (a/m)	O₂ Sup (n)	FEV₁ (%pred)	Falls 12m (n)
Mclay et al.²¹21 McLay R, Kirkwood RN, Kuspinar A, Richardson J, Wald J, Raghavan N, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chronic Respiratory Disease[Internet]. 2020;17. Disponível em: https://doi.org/10.1177/1479973120922538 https://doi.org/10.1177/1479973120922538... ,	86	45	41	86	0	0	72.9(±6.8)	46.0(±27.0)	25(±29.1)	47.3(±20.3)	34
Crisan et al.²²22 Crişan AF, Oancea C, Timar B, Fira-Mladinescu O, Tudorache V. Balance impairment in patients with COPD. PloS one [Internet]. 2015;10(3): e0120573. Disponível em: https://doi.org/10.1371/journal.pone.0120573 https://doi.org/10.1371/journal.pone.012... ,	46	NM	NM	29	17	0	62.5(±5.0)	>10	NM	NM	17
Jacome et al.²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391 https://doi.org/10.2522/ptj.20150391... ,	46	24	22	46	0	0	75.9 (±7.1)	NM	NM	69.4(±19.9)	23
Oliveira et al. ²⁴24 Oliveira CC, McGinley J, Lee AL, Irving LB, Denehy L. Fear of falling in people with chronic obstructive pulmonary disease. Respir Med[Internet]. 2015;109(4):483-9. Disponível em: https://doi.org/10.1016/j.rmed.2015.02.003 https://doi.org/10.1016/j.rmed.2015.02.0... ,	40	19	21	40	0	25	71(±8.1)	49.6 (±25.8)	18	45.1(±16.2)	13
Ozalevli et al. ²⁵25 Ozalevli S, Ilgin D, Narin S, Akkoclu A. Association between disease-related factors and balance and falls among the elderly with COPD: a cross-sectional study. Aging Clinical and Experimental Research[Internet]. 2011;23(5-6):372–7.Disponível em: https://doi.org/10.1007/bf03325235 https://doi.org/10.1007/bf03325235... ,	36	25	11	36	0	20	70.3(±3.0)	42.1(±11.2)	NM	43.5(±6)	10
Voica et al.²⁶26 Voica A ,Oancea C, Tudorache E, Crisan A, Fira-Mladinescu O, Tudorache V, et al. Chronic obstructive pulmonary disease phenotypes and balance impairment. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2016; 11(1):919-925. Disponível em: https://doi.org/10.2147/COPD.S101128 https://doi.org/10.2147/COPD.S101128... ,	27	NM	NM	27	0	17	NM	>10	NM	NM	NM
Nantsupawat et al.²⁷27 Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207 https://doi.org/10.1177/2150131915577207... ,	14	8	6	14	0	0	69.7(±6.0)	NM	3(±21.4)	36.9(±.6)	3
Muti et al.²⁸28 Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752 https://doi.org/10.3390/jcm8101752... ,	50	NM	NM	50	0	0	66.2(±8.2)	NM	NM	51.8(±15.9)	23
Porto el al. ²⁹29 Porto EF, Pradella CO, Rocco CM, Chueiro M, Jr., Maia RQ, Ganança FF, et al. Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2017;37(2):139–45. Disponível em: https://doi.org/10.1097/HCR.0000000000000246 https://doi.org/10.1097/HCR.000000000000... ,	132	72	60	132	0	39	67.3(±10)	49.1(±23)	NM	89.2(±23.6)	35
Hellstrom et al.³⁰30 Hellström K, Vahlberg B, Urell C, Emtner M. Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease. Clinical Rehabilitation[Internet]. 2009;23(12):1136–44. Disponível em: https://doi.org/10.1177/0269215509342329 https://doi.org/10.1177/0269215509342329... ,	80	29	51	80	0	0	65(±9.0)	NM	NM	47.5(±13)	20
Park et al.³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609 https://doi.org/10.3390/jcm9020609... ,	34	14	20	34	0	22	68.9(±1.3)	NM	20	44.1(±3.1)	21
Mkacher et al.³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240 https://doi.org/10.1097/HCR.000000000000... ,	60	NM	NM	60	0	0	61.2(±3.2)	0	NM	58.6(±8.6)	NM
Beauchamp et al.⁸8 Beauchamp MK. Balance assessment in people with COPD: An evidence-based guide. Chronic Respiratory Disease [Internet]. 2019; 16. Disponível em: https://doi.org/10.1177/1479973118820311 https://doi.org/10.1177/1479973118820311... ,	39	18	21	39	0	0	71.1(±6.8)	>10	18	41.5(±17)	18
Al Haddad et al.³³33 Al Haddad MA, John M, Hussain S, Bolton CE. Role of the Timed Up and Go Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention[Internet]. 2016;36(1):49–55. Disponível em: https://doi.org/10.1097/hcr.0000000000000143 https://doi.org/10.1097/hcr.000000000000... ,	132	74	62	132	0	58	68(±8.0)	46.0(±26)	NM	59(±18)	27
Singh et al.³⁴34 Singh SS, Bhat A, Mohapatra AK, Manu MK, Vaishali K. Comparison of reaction time and functional balance in chronic obstructive pulmonary disease and healthy participants. Heart & Lung[Internet]. 2019; Disponível em: https://doi.org/10.1016/j.hrtlng.2019.09.006 https://doi.org/10.1016/j.hrtlng.2019.09... ,	41	38	3	41	0	41	NM	NM	0	47.6(±17.9)	NM
Pereira et al.³⁵35 Pereira A, Xavier RF, Lopes AC, da Silva C, Oliveira CC, Fernandes FLA, et al. The Mini-Balance Evaluation System Test Can Predict Falls in Clinically Stable Outpatients With COPD: A 12-MO PROSPECTIVE COHORT STUDY. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2019;39(6):391–6. Disponível em: https://doi.org/10.1097/HCR.0000000000000427 https://doi.org/10.1097/HCR.000000000000... ,	70	46	23	70	0	0	67(±9.3)	56.0 (±38.2)	0	42.7(±14.2)	29
Harrison et al.³⁶36 Harrison SL, Beauchamp MK, Sibley K, Araujo T, Romano J, Goldstein RS, et al. Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease. BMC Pulmonary Medicine[Internet]. 2015;15(1).Disponível em: https://doi.org/10.1186/s12890-015-0067-2 https://doi.org/10.1186/s12890-015-0067-... ,	32	17	15	32	0	0	68.5(±9.9)	62.3 (±30.4)	NM	38.2(±14.7)	NM
Roig et al.¹⁴14 Roig M, Eng JJ, Road JD, Reid WD. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory medicine [Internet]. 2009;103(9):1257–69. Disponível em: https://doi.org/10.1016/j.rmed.2009.03.022 https://doi.org/10.1016/j.rmed.2009.03.0... ,	20	NM	NM	20	0	20	72.3(±6.7)	NM	0	46.7(±13.0)	4
Roig et al.³⁷37 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 [Internet]. 2011;105(3):461–9. Disponível em: https://doi.org/10.1016/j.rmed.2010.08.015 https://doi.org/10.1016/j.rmed.2010.08.0... ,	101	56	45	101	0	0	NM	NM	31	43.4(±36.9)	32
Tudorache et al.³⁸38 Tudorache E, Oancea C, Avram C, Fira-Mladinescu O, Petrescu L, Timar B. Balance impairment and systemic inflammation in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2015; 10(1):1847-1852. Disponível em: https://doi.org/10.2147/copd.s89814 https://doi.org/10.2147/copd.s89814... ,	61	NM	NM	22	19	20	60(±4.0)	>20	0	27.5(±7.0)	NM
De Castro et al.³⁹39 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 With Healthy Controls and Differences According to Sex and Disease Severity. Respiratory care [Internet]. 2016;61(11):1488–96. Disponível em: https://doi.org/10.4187/respcare.04749 https://doi.org/10.4187/respcare.04749... ,	72	27	20	47	0	25	68(±5.0)	NM	NM	45(±15)	NM

Study	Year	Content Validity	Construct Validity	Internal Cons.	Transcul.Validity	Reliab.	Measure Error	Criterion Validity	Hypot. Test	Respons.	Final Class.
Mclay et al.²¹21 McLay R, Kirkwood RN, Kuspinar A, Richardson J, Wald J, Raghavan N, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chronic Respiratory Disease[Internet]. 2020;17. Disponível em: https://doi.org/10.1177/1479973120922538 https://doi.org/10.1177/1479973120922538... ,	2020	A/+	N/I	N/I	N/I	N/I	N/I	N/I	O/+	N/I	A/+
Harrison et al.³⁶36 Harrison SL, Beauchamp MK, Sibley K, Araujo T, Romano J, Goldstein RS, et al. Minimizing the evidence-practice gap - a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease. BMC Pulmonary Medicine[Internet]. 2015;15(1).Disponível em: https://doi.org/10.1186/s12890-015-0067-2 https://doi.org/10.1186/s12890-015-0067-... ,	2019	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	A/-	A/-
Voica et al.²⁶26 Voica A ,Oancea C, Tudorache E, Crisan A, Fira-Mladinescu O, Tudorache V, et al. Chronic obstructive pulmonary disease phenotypes and balance impairment. International Journal of Chronic Obstructive Pulmonary Disease [Internet]. 2016; 11(1):919-925. Disponível em: https://doi.org/10.2147/COPD.S101128 https://doi.org/10.2147/COPD.S101128... ,	2016	A/?	N/I	N/I	N/I	N/I	N/I	N/I	A/-	N/I	A/?
Hellstrom et al.³⁰30 Hellström K, Vahlberg B, Urell C, Emtner M. Fear of falling, fall-related self-efficacy, anxiety and depression in individuals with chronic obstructive pulmonary disease. Clinical Rehabilitation[Internet]. 2009;23(12):1136–44. Disponível em: https://doi.org/10.1177/0269215509342329 https://doi.org/10.1177/0269215509342329... ,	2009	A/?	N/I	N/I	D/?	N/I	N/I	N/I	D/-	N/I	D/-
Nantsupawat et al.²⁷27 Nantsupawat N, Lane P, Siangpraipunt O, Gadwala S, Nugent K. Gait Characteristics in Patients With Chronic Obstructive Pulmonary Disease. Journal of Primary Care & Community Health[Internet]. 2015;6(4):222–6. Disponível em: https://doi.org/10.1177/2150131915577207 https://doi.org/10.1177/2150131915577207... ,	2015	A/?	N/I	N/I	N/I	N/I	N/I	N/I	D/-	N/I	D/-
Muti et al.²⁸28 Reynaud V, Muti D, Pereira B, Greil A, Caillaud D, Richard R, et al. A TUG Value Longer Than 11 s Predicts Fall Risk at 6-Month in Individuals with COPD. Journal of Clinical Medicine[Internet]. 2019;8(10):1752. Disponível em: https://doi.org/10.3390/jcm8101752 https://doi.org/10.3390/jcm8101752... ,	2019	A/+	N/I	N/I	N/I	A/ +	N/I	N/I	A/+	N/I	A/+
Roig et al.¹⁵15 Mokkink LB, de Vet HCW, Prinsen CAC, Patrick DL, Alonso J, Bouter LM, et al. COSMIN Risk of Bias checklist for systematic reviews of Patient-Reported Outcome Measures Quality of Life Research [Internet]. 2017;27(5):1171–9. Disponível em: https://doi.org/10.1007/s11136-017-1765-4 https://doi.org/10.1007/s11136-017-1765-... ,	2012	A/-	N/I	N/I	N/I	N/I	N/I	N/I	D/?	N/I	D/?
Porto el al.²⁹29 Porto EF, Pradella CO, Rocco CM, Chueiro M, Jr., Maia RQ, Ganança FF, et al. Comparative Postural Control in COPD Patients and Healthy Individuals During Dynamic and Static Activities. Journal of Cardiopulmonary Rehabilitation and Prevention [Internet]. 2017;37(2):139–45. Disponível em: https://doi.org/10.1097/HCR.0000000000000246 https://doi.org/10.1097/HCR.000000000000... ,	2017	A/+	N/I	N/I	N/I	A/+	N/I	N/I	A/+	N/I	A/+
Jacome et al.²³23 Jácome C, Cruz J, Oliveira A, Marques A. Validity, Reliability, and Ability to Identify Fall Status of the Berg Balance Scale, BESTest, Mini-BESTest, and Brief-BESTest in Patients With COPD. Physical therapy [Internet]. 2016;96(11):1807–15.Disponível em: https://doi.org/10.2522/ptj.20150391 https://doi.org/10.2522/ptj.20150391... ,	2016	A/+	N/I	N/I	N/I	A/+	A/-	A/+	A/+	N/I	A/-
Park et al.³¹31 Park JK, Deutz NEP, Cruthirds CL, Kirschner SK, Park H, Madigan ML, et al. Risk Factors for Postural and Functional Balance Impairment in Patients with Chronic Obstructive Pulmonary Disease. Journal of Clinical Medicine[Internet]. 2020;9(2):609. Disponível em: https://doi.org/10.3390/jcm9020609 https://doi.org/10.3390/jcm9020609... ,	2020	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Mkacher et al.³²32 Mkacher W, Tabka Z, Trabelsi Y. Minimal Detectable Change for Balance Measurements in Patients With COPD. Journal of cardiopulmonary rehabilitation and prevention [Internet]. 2017;37(3):223–8. Disponível em: https://doi.org/10.1097/HCR.0000000000000240 https://doi.org/10.1097/HCR.000000000000... ,	2017	A/+	N/I	N/I	N/I	A/+	A/-	N/I	A/+	N/I	A/-
de Castro et al.³⁹39 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 With Healthy Controls and Differences According to Sex and Disease Severity. Respiratory care [Internet]. 2016;61(11):1488–96. Disponível em: https://doi.org/10.4187/respcare.04749 https://doi.org/10.4187/respcare.04749... ,	2016	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Al Haddad et al.³³33 Al Haddad MA, John M, Hussain S, Bolton CE. Role of the Timed Up and Go Test in Patients With Chronic Obstructive Pulmonary Disease. Journal of Cardiopulmonary Rehabilitation and Prevention[Internet]. 2016;36(1):49–55. Disponível em: https://doi.org/10.1097/hcr.0000000000000143 https://doi.org/10.1097/hcr.000000000000... ,	2016	A/+	N/I	N/I	N/I	A/+	N/I	N/I	A/+	N/I	A/+
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Instrument	ICC	Sample	Quality of evidence	Recommendation
BBS	0.82-0.93	106	High	A
BESTest	0.87	46	Low	C
MiniBESTest	0.88	46	Low	C
TUG	0.91-0.95	237	High	A
Brief-BESTTest	0.82	46	Low	C
UST	0.91	60	Moderate	C

Brasil

Brasil

Balance, falls, and risk of falls in COPD: systematic review of assessment instruments, measurement properties, and clinical utility

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