Avaliação crítica das propriedades psicométricas de testes de capacidade funcional em pacientes pós-Covid-19: implicações para reabilitação e intervenção clínica

Abstract

COVID-19 is an infectious disease that induces various systemic manifestations during its acute stage, potentially resulting in severe acute respiratory syndrome in many cases. In the subsequent phase, known as post-COVID-19, it is widely recognized that some patients experience reduced exercise tolerance and quality of life. During the COVID-19 pandemic, significant progress was made in understanding the repercussions of these manifestations on the cardiopulmonary and musculoskeletal systems, from functional limitations to optimized strategies for clinical identification and intervention. Exercise capacity assessment has proven essential for identifying functional deterioration and planning the rehabilitation process in post-COVID-19 survivors. However, the psychometric properties of the tests used have not been sufficiently investigated, highlighting the need for studies to validate these tools to ensure more effective and personalized interventions. Therefore, the general objective of this thesis is to assess the psychometric properties of exercise capacity tests used in post-COVID-19 patients and synthesize evidence on the effectiveness of these tests for rehabilitation and clinical intervention. Methods: This thesis was conducted in two stages. The first stage involved registering the systematic review (SR) protocol, followed by conducting the systematic review itself. The SR protocol focuses on the psychometric properties (validity, reliability [internal consistency and measurement error], learning effects, test repetition, familiarity, responsiveness, and interpretability) of physical performance tests such as cardiopulmonary exercise tests (CEPT), including the 6-minute walk test (6MWT), incremental shuttle walk test (ISWT), endurance shuttle walk test (ESWT), sit-to-stand test (STST), short physical performance battery (SPPB), and the step test (ST) in post-COVID-19 patients. This protocol was developed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines; it was registered on the PROSPERO platform (CRD42021242334) and published in the journal BMJ Open. During the second phase, the actual SR execution, studies involving post-COVID-19 patients assessed only by the 6MWT were included. Searches were conducted in the following databases: PubMed/MEDLINE, EMBASE, SciELO, Cochrane Library, CINAHL, and Web of Science. The research included randomized clinical trials (RCTs), quasi-RCTs, and observational studies conducted in hospital, rehabilitation center, and outpatient clinic settings, published in English, with no date restriction, involving adult post-COVID-19 patients over 18 years old with a confirmed diagnosis of COVID-19. All assessment stages were conducted by two independent researchers, and in cases of disagreement, a third evaluator was consulted. The risk of bias was analyzed using COSMIN and the certainty of the evidence assessment was determined by the modified GRADE. Results: A total of 8,890 articles were identified, and only 20 articles included for the psychometric property's analysis. The psychometric properties assessed were validity and responsiveness, with one study assessing construct validity, 12 studies assessing validity compared to subgroups, and 15 studies assessing responsiveness, including one study comparing subgroups and 14 pre- and post-intervention studies. For validity, only 6 studies confirmed the hypothesis, with an overall insufficient rating and very low evidence quality. For responsiveness, the overall rating was classified as insufficient and low-quality evidence. Conclusions: It can be inferred that the 6MWT has potential for assessing functional capacity in post-COVID-19 patients, but current evidence on its validity and responsiveness is limited. Only a few studies have confirmed its validity and responsiveness, with the majority presenting low-quality evidence. There is a need for further studies with more appropriate methodological criteria, aiming at more effective and personalized interventions in rehabilitation using the 6-Minute Walk Test (6MWT) in post-COVID-19 patients.