Equilíbrio, quedas e risco de quedas na DPOC: revisão sistemática dos instrumentos de avaliação, propriedades de medida e utilidade clínica

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

doi:10.1590/1981-22562024027.230189.pt

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Revista Brasileira de Geriatria e Gerontologia

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Sumário

Artigos de Revisão • Rev. bras. geriatr. gerontol. 27 • 2024 • https://doi.org/10.1590/1981-22562024027.230189.pt copiar

Equilíbrio, quedas e risco de quedas na DPOC: revisão sistemática dos instrumentos de avaliação, propriedades de medida e utilidade clínica

Autoria SCIMAGO INSTITUTIONS RANKINGS

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

Estudos	DPOC (n)	M (n)	F (n)	DPOC Est (n)	DPOC Exa (n)	Contr (n)	Idade (anos)	Tabag (a/m)	O₂ Supl (n)	FEV₁ (%pred)	Quedas 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	NC	NC	29	17	0	62,5(±5,0)	>10	NC	NC	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)	NC	NC	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)	NC	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	NC	NC	27	0	17	NC	>10	NC	NC	NC
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)	NC	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	NC	NC	50	0	0	66,2(±8,2)	NC	NC	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)	NC	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)	NC	NC	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)	NC	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	NC	NC	60	0	0	61,2(±3,2)	0	NC	58,6(±8,6)	NC
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)	NC	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	NC	NC	0	47,6(±17,9)	NC
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)	NC	38,2(±14,7)	NC
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	NC	NC	20	0	20	72,3(±6,7)	NC	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	NC	NC	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	NC	NC	22	19	20	60(±4,0)	>20	0	27,5(±7,0)	NC
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)	NC	NC	45(±15)	NC

Estudo	Ano	Validade Conteúdo	Validade Construto	Cons. Interna	Validade Transcul.	Confiab.	Erro Medida	Validade Critério	Teste Hipot.	Respons.	Class. Final
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/+
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... ,	2015	A/-	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/-
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... ,	2011	A/-	N/I	N/I	N/I	N/I	N/I	N/I	A/-	N/I	A/-
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... ,	2019	A/-	N/I	N/I	N/I	N/I	N/I	N/I	D/-	N/I	D/-
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... ,	2019	A/+	N/I	N/I	A/+	N/I	N/I	A/+	A/+	N/I	A/+
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... ,	2009	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
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... ,	2015	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+
Roig et al³⁷37 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... ,	2011	A/+	N/I	N/I	N/I	N/I	N/I	N/I	A/+	N/I	A/+

Instrumento	ICC	Amostra	Qualidade da evidência	Recomendação
BBS	0,82-0,93	106	Alta	A
BESTest	0,87	46	Baixa	C
MiniBESTest	0.88	46	Baixa	C
TUG	0,91-0,95	237	Alta	A
Brief-BESTTest	0,82	46	Baixa	C
UST	0,91	60	Moderada	C

Instrumento	Tempo de administração	Custo total	Portabilidade equipamento	Equipamento treinamento	Pontuação final
BBS	2	3	2	2	9
BESTest	1	3	2	2	8
MiniBESTest	2	3	2	2	9
TUG	3	3	2	2	10
Brief-BESTTest	3	3	2	2	10
UST	3	3	2	2	10

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[1] Correspondência/ Silvia Vaderramas svalderramas@uol.com.br

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Equilíbrio, quedas e risco de quedas na DPOC: revisão sistemática dos instrumentos de avaliação, propriedades de medida e utilidade clínica

Resumo

﻿Objetivos

Método

Resultados

Conclusão

Objetivos