The modified Medical Research Council (mMRC) and COPD Assessment Test (CAT) are assessment instruments associated with level of physical activity of daily living (PADL) in patients with COPD. This study aimed to identify mMRC and CAT cutoff points to discriminate sedentary behavior and PADL level of subjects with COPD and verify whether these cutoff points differentiate pulmonary function, health-related quality of life (HRQOL), functional status, and mortality index in subjects with COPD.
METHODS:
Subjects (N = 131, FEV1: 36.7 ± 16.1% predicted) were assessed for lung function, mMRC, CAT, HRQOL, functional status, and mortality index. PADL was monitored using a triaxial accelerometer, and subjects were classified as sedentary/nonsedentary (cutoff point of 8.5 h/d in PADL < 1.5 metabolic equivalent of task [MET]), physically active/inactive (cutoff point of 80 min/d in PADL ≥ 3 METs), and with/without severe physical inactivity (cutoff point of 4,580 steps/d), according to variables provided by accelerometer.
RESULTS:
ROC curve indicated mMRC cutoff point of ≥ 2 (P < .05) for physical inactivity (sensitivity = 66%, specificity = 56%, AUC = 0.62), severe physical inactivity (sensitivity = 81%, specificity = 66%, AUC = 0.76), and sedentary behavior (sensitivity = 61%, specificity = 70%, AUC = 0.65). The identified CAT cutoff points were ≥ 16 and ≥ 20, considering severe physical inactivity (sensitivity = 76%, specificity = 54%, AUC = 0.69, P < .001) and sedentary behavior (sensitivity = 51%, specificity = 90%, AUC = 0.71, P = .001), respectively. Subjects who had mMRC ≥ 2 and CAT ≥ 16 or ≥ 20 presented worse pulmonary function, HRQOL, functional status, and mortality index compared with those who scored mMRC < 2 and CAT <16 or < 20.
CONCLUSIONS:
mMRC cutoff point of ≥ 2 is recommended to discriminate PADL level and sedentary behavior, whereas CAT cutoff points of ≥ 16 and ≥ 20 discriminated severe physical inactivity and sedentary behavior, respectively. These cutoff points differentiated subjects with COPD regarding all the outcomes assessed in this study.
SpruitMA, SinghSJ, GarveyC, ZuWallackR, NiciL, RochesterC, et al. ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med, 2013; 188(8):e13-64-e64.
2.
NishimuraK, IzumiT, TsukinoM, OgaT. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest, 2002; 121(5):1434-1440.
3.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2020 Report. Available at: http://www.goldcopd.org/. Accessed November 4,2020.
4.
LeidyN. On functional status and the forward progress of merry-go-rounds: toward a coherent analytical framework. Nursing Research, 1994; 43(4):196-202.
5.
WatzH, PittaF, RochesterCL, Garcia-AymerichJ, ZuWallackR, TroostersT, et al. An official European Respiratory Society statement on physical activity in COPD. Eur Respir J, 2014; 44(6):1521-1537.
6.
KocksJW, AsijeeGM, TsiligianniIG, KerstjensHA, van der MolenT. Functional status measurement in COPD: a review of available methods and their feasibility in primary care. Prim Care Respir J, 2011; 20(3):269-275.
7.
DurrS, ZoggS, MiedingerD, StevelingEH, MaierS, LeuppiJD. Daily physical activity, functional capacity, and quality of life in patients with COPD. COPD, 2014; 11(6):689-696.
8.
Garcia-AymerichJ, LangeP, BenetM, SchnohrP, AntoJM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population-based cohort study. Thorax, 2006; 61(9):772-778.
9.
WaschkiB, KirstenA, HolzO, MullerKC, MeyerT, WatzH, et al. Physical activity is the strongest predictor of all-cause mortality in patients with COPD: a prospective cohort study. Chest, 2011; 140(2):331-342.
10.
PittaF, TroostersT, ProbstVS, SpruitMA, DecramerM, GosselinkR. Quantifying physical activity in daily life with questionnaires and motion sensors in COPD. Eur Respir J, 2006; 27(5):1040-1055.
11.
FurlanettoKC, DonariaL, SchneiderLP, LopesJR, RibeiroM, FernandesKB, et al. Sedentary behavior is an independent predictor of mortality in subjects with COPD. Respir Care, 2017; 62(5):579-587.
12.
van RemoortelH, CamilloCA, LangerD, HornikxM, DemeyerH, BurtinC, et al. Moderate intense physical activity depends on selected metabolic equivalent of task (MET) cutoff and type of data analysis. PloS One, 2013; 8(12):e84365.
13.
DepewZS, NovotnyPJ, BenzoRP. How many steps are enough to avoid severe physical inactivity in patients with chronic obstructive pulmonary disease?. Respirology, 2012; 17(6):1026-1027.
14.
ParkSK, MeldrumCA, LarsonJL. Subgroup analysis of symptoms and their effect on functioning, exercise capacity, and physical activity in patients with severe chronic obstructive pulmonary disease. Heart Lung, 2013; 42(6):465-472.
15.
PolkeyMI, MoxhamJ. Attacking the disease spiral in chronic obstructive pulmonary disease: an update. Clin Med (Lond), 2011; 11(5):461-464.
16.
DemeyerH, Gimeno-SantosE, RabinovichRA, HornikxM, LouvarisZ, de BoerWI, et al. PROactive consortium. Physical activity characteristics across GOLD quadrants depend on the questionnaire used. PloS One, 2016; 11(3):e0151255.
17.
MunariAB, GulartAA, Dos SantosK, VenancioRS, KarlohM, MayerAF. Modified medical research council dyspnea scale in GOLD classification better reflects physical activities of daily living. Respir Care, 2018; 63(1):77-85.
18.
ZoggS, DurrS, MiedingerD, StevelingEH, MaierS, LeuppiJD. Differences in classification of COPD patients into risk groups A-D: a cross-sectional study. BMC Res Notes, 2014; 7:562.
19.
KarlohM, Fleig MayerA, MauriciR, PizzichiniMM, JonesPW, PizzichiniE. The COPD assessment test: what do we know so far?: a systematic review and meta-analysis about clinical outcomes prediction and classification of patients into GOLD stages. Chest, 2016; 149(2):413-425.
20.
SmidDE, FranssenFME, GonikM, MiravitllesM, CasanovaC, CosioBG, et al. Redefining cut-points for high symptom burden of the global initiative for chronic obstructive lung disease classification in 18,577 patients with chronic obstructive pulmonary disease. Journal of the American Medical Directors Association, 2017; 18(12):e1011-1097-1097.e24. 1097e1024.
21.
SillenMJ, FranssenFM, DelbressineJM, Uszko-LencerNH, VanfleterenLE, RuttenEP, et al. Heterogeneity in clinical characteristics and comorbidities in dyspneic individuals with COPD GOLD D: findings of the DICES trial. Respir Med, 2013; 107(8):1186-1194.
22.
MillerMR, HankinsonJ, BrusascoV, BurgosF, CasaburiR, CoatesA, et al. ATS/ERS Task Force. Standardization of spirometry. Eur Respir J, 2005; 26(2):319-338.
23.
PereiraCA, SatoT, RodriguesSC. New reference values for forced spirometry in white adults in Brazil. J Bras Pneumol, 2007; 33(4):397-406.
24.
JonesPW, HardingG, BerryP, WiklundI, ChenWH, Kline LeidyN. Development and first validation of the COPD assessment test. Eur Respir J, 2009; 34(3):648-654.
25.
SilvaGP, MoranoMT, VianaCM, MagalhaesCB, PereiraED. Portuguese-language version of the COPD assessment test: validation for use in Brazil. J Bras Pneumol, 2013; 39(4):402-408.
26.
JonesPW, QuirkFH, BaveystockCM. The St George's respiratory questionnaire. Respir Med, 1991; 85 Suppl B(Suppl B):25-31, discussion 33–27.
27.
CamelierA, RosaFW, SalmiC, NascimentoOA, CardosoF, JardimJR. Using the Saint George's respiratory questionnaire to evaluate quality of life in patients with chronic obstructive pulmonary disease: validating a new version for use in Brazil. J Bras Pneumol, 2006; 32(2):114-122.
28.
CarpesMF, MayerAF, SimonKM, JardimJR, GarrodR. The Brazilian Portuguese version of the London chest activity of daily living scale for use in patients with chronic obstructive pulmonary disease. J Bras Pneumol, 2008; 34(3):143-151.
29.
GarrodR, BestallJC, PaulEA, WedzichaJA, JonesPW. Development and validation of a standardized measure of activity of daily living in patients with severe COPD: the London chest activity of daily living scale (LCADL). Respir Med, 2000; 94(6):589-596.
30.
GulartAA, MunariAB, KleinSR, VenancioRS, AlexandreHF, MayerAF. The London chest activity of daily living scale cutoff point to discriminate functional status in patients with chronic obstructive pulmonary disease. Braz J Phys Ther, 2020 May-Jun;24(3):264-272.
31.
HollandAE, SpruitMA, TroostersT, PuhanMA, PepinV, SaeyD, et al. An official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease. Eur Respir J, 2014; 44(6):1428-1446.
32.
BrittoRR, ProbstVS, de AndradeAF, SamoraGA, HernandesNA, MarinhoPE, et al. Reference equations for the 6-minute walk distance based on a Brazilian multicenter study. Braz J Phys Ther, 2013; 17(6):556-563.
33.
TroostersT, GosselinkR, DecramerM. Six minute walking distance in healthy elderly subjects. Eur Respir J, 1999; 14(2):270-274.
34.
SkumlienS, HagelundT, BjortuftO, RygMS. A field test of functional status as performance of activities of daily living in COPD patients. Respir Med, 2006; 100(2):316-323.
35.
ReisCMD, KarlohM, FonsecaFR, BiscaroRRM, MazoGZ, MayerAF. Functional capacity measurement: reference equations for the Glittre activities of daily living test. J Bras Pneumol, 2018; 44(5):370-377.
36.
GulartAA, MunariAB, KleinSR, Santos da SilveiraL, MayerAF. The Glittre-ADL test cutoff point to discriminate abnormal functional capacity in patients with COPD. COPD, 2018; 15(1):73-78.
37.
CelliBR, CoteCG, MarinJM, CasanovaC, Montes de OcaM, MendezRA, et al. The body mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. The.N Engl J Med, 2004; 350(10):1005-1012.
38.
PittaF, TroostersT, SpruitMA, ProbstVS, DecramerM, GosselinkR. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 2005; 171(9):972-977.
39.
RumseyD. Statistics for Dummies. 2d ed. Wiley; 2016.
40.
MandrekarJN. Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol, 2010; 5(9):1315-1316.
41.
CasanovaC, MarinJM, Martinez-GonzalezC, de Lucas-RamosP, Mir-ViladrichI, CosioB, et al. Differential effect of modified medical research council dyspnea, COPD assessment test, and clinical COPD questionnaire for symptoms evaluation within the new GOLD staging and mortality in COPD. Chest, 2015; 148(1):159-168.
42.
JonesP, AdamekL, NadeauG, BanikN. Comparisons of health status scores with MRC grades in a primary care COPD population: implications for the new GOLD 2011 classification. Eur Respir J, 2013; 42(3):647-654.
43.
CaroneM, AntoniuS, BaiardiP, DigilioVS, JonesPW, BertolottiG. QuESS Group. Predictors of mortality in patients with COPD and chronic respiratory failure: the quality-of-life evaluation and survival study (QuESS): A 3-Year Study. COPD, 2016; 13(2):130-138.
44.
DajczmanE, WardiniR, KasymjanovaG, PrefontaineD, BaltzanMA, WolkoveN. Six-minute walk distance is a predictor of survival in patients with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation. Canadian Respiratory Journal, 2015; 22(4):225-229.
45.
JonesPW. St. George's respiratory questionnaire: MCID. COPD, 2005; 2(1):75-79.
46.
GulartAA, AraujoCLP, MunariAB, SantosKD, KarlohM, FoscariniBG, et al. The minimal important difference for Glittre-ADL test in patients with chronic obstructive pulmonary disease. Braz J Phys Ther, 2020; 24(1):54-60.
47.
Almeida GulartA, de AraujoCLP, Bauer MunariA, SchneiderBF, Dal LagoP, MayerAF. Minimal important difference for London chest activity of daily living scale in patients with chronic obstructive pulmonary disease. Physiotherapy, 2020; 107:28-35.
48.
DemeyerH, BurtinC, HornikxM, CamilloCA, Van RemoortelH, LangerD, et al. The minimal important difference in physical activity in patients with COPD. PloS One, 2016; 11(4):e0154587.
49.
GulartA, SantosK, MunariA, KarlohM, CaniK, MayerA. Relationship between the functional capacity and perception of limitation on activities of daily life of patients with.COPD. Fisioter e Pesqui, 2015; 22(2).
50.
GulartAA, MunariAB, QueirozAPAD, CaniKC, MatteDL, MayerAF. Does the COPD assessment test reflect functional status in patients with COPD?. Chron Respir Dis, 2017; 14(1):37-44.
51.
KarlohM, AraujoCL, GulartAA, ReisCM, SteidleLJ, MayerAF. The Glittre-ADL test reflects functional performance measured by physical activities of daily living in patients with chronic obstructive pulmonary disease. Braz J Phys Ther, 2016; 20(3):223-230.
52.
HillK, GardinerPA, CavalheriV, JenkinsSC, HealyGN. Physical activity and sedentary behavior: applying lessons to chronic obstructive pulmonary disease. Intern Med J, 2015; 45(5):474-482.
53.
GulartAA, MunariAB, Santos SilvaIJC, AlexandreHF, KarlohM, MayerAF. Baseline characteristics associated to improvement of patients with COPD in physical activity in daily life level after pulmonary rehabilitation. Respir Med, 2019; 151:142-147.
