The validity and reliability of the ADL-Glittre test for

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Apr 16, 2018 - To cite this article: Renata Martins, Maíra S. de Assumpção, Tatiana G. Bobbio ... Renata Martins, MSc, PTa, Maíra S. de Assumpção, MSc, PTa, ...
Physiotherapy Theory and Practice An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20

The validity and reliability of the ADL-Glittre test for children Renata Martins, Maíra S. de Assumpção, Tatiana G. Bobbio, Anamaria F. Mayer & Camila Schivinski To cite this article: Renata Martins, Maíra S. de Assumpção, Tatiana G. Bobbio, Anamaria F. Mayer & Camila Schivinski (2018): The validity and reliability of the ADL-Glittre test for children, Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2018.1457747 To link to this article: https://doi.org/10.1080/09593985.2018.1457747

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PHYSIOTHERAPY THEORY AND PRACTICE https://doi.org/10.1080/09593985.2018.1457747

The validity and reliability of the ADL-Glittre test for children Renata Martins, MSc, PTa, Maíra S. de Assumpção, MSc, PTa, Tatiana G. Bobbio, PhD, PTb, Anamaria F. Mayer, PhD, PTa, and Camila Schivinski, PhD, PTa a

Department of Physical Therapy, Santa Catarina State University, Florianópolis, Santa Catarina, Brasil; bMotor Neuroscience, Texas A&M University, College Station, TX USA ABSTRACT

ARTICLE HISTORY

Objective: The ADL-Glittre was created to assess more comprehensively the essential activities of daily living in adults with chronic obstructive pulmonary disease. The aim of this study was to validate the ADL-Glittre test adapted for children (TGlittre-P) and verify its reliability. Methods: This is a cross-sectional study with 87 healthy children aged 6 to 14 years (mean 10.36 ± 2.32 years). Biometric and spirometry data were collected from all participants. On the same day, part of the sample (36 children included in the validation process) performed two 6MWT and two TGlittre-P (30-minute interval between them). The other part of the sample just performed two TGlittre-P for the reliability process. Pearson and Spearman correlation tests were used to verify the correlation between the time spent on the TGlittre-P and the distance walked in the 6MWT. The intraclass correlation coefficient (ICC) was also used to assess the reproducibility of the TGlittre-P. Results: The TGlittre-P showed a moderate negative correlation with the 6MWT (r = −0.490; p = 0.002; 95%CI −0.712 to −0.233). However, the behavior of the physiological variables that were monitored during the tests was similar and showed to be reproducible (ICC = 0.843; p = 0.000; 95%CI 0.695 to 0.911). Conclusion: The TGlittre-P proved to be a valid and reliable assessment of the functional capacity of healthy children aged 6 to 14 years.

Received 20 July 2017 Revised 15 October 2017 Accepted 11 November 2017

Introduction Children with lung disease often show loss of physical capacity, and consequently, limitations in activities of daily living (ADL) (Andrade et al., 2014; Aznar et al., 2014). Tests of functional capacity and exercise tolerance are crucial for clinical evaluations in this population (Kocks et al., 2011). Most ADL are performed at submaximal intensity; therefore, submaximal functional tests have been proposed for the assessment of physical capacity (Pitta et al., 2005). Therefore, functional tests, such as the six-minute walk test (6MWT), a classic endurance test involving a typical daily activity, have been able to detect the limitations of ADL performance (Pitta et al., 2005; Solway, Brooks, Lacasse, and Thomas, 2001), even though this is not the main objective of the test. This evidence has been observed in children, adolescents, and adults (Geiger et al., 2007; Pitta et al., 2005; Solway, Brooks, Lacasse, and Thomas, 2001). However, recent studies have found that anthropometric data, age, and gender may influence the performance of the 6MWT when administered in children (Martins, Gonçalves, Mayer, and Schivinski, 2014;

KEYWORDS

Activities of daily living; child; outcome assessment; reproducibility of results

Okuro and Schivinski, 2013). In addition, as the 6MWT simply involves walking, it does not consider the assessment of activities involving the upper limbs, therefore providing an incomplete evaluation (Skumlien, Hagelund, Bjørtuft, and Ryg, 2006). In this context, the ADL-Glittre test (TGlittre) has recently emerged as a more reliable and complete alternative to evaluate ADL using the upper limbs. This test aims to assess more comprehensively the essential ADL in subjects with chronic obstructive pulmonary disease, as it examines other activities in addition to walking, such as sitting and standing up from a chair, walking up and down stairs, and moving objects with the upper limbs (Skumlien, Hagelund, Bjørtuft, and Ryg, 2006). A correlation between the TGlittre and the 6MWT conducted on healthy adults (Corrêa et al., 2011) with chronic obstructive pulmonary disease could be observed (Skumlien, Hagelund, Bjørtuft, and Ryg, 2006). However, there are very few studies about the TGlittre reported in the literature, in which most of the tests are performed on adults (Arikan et al., 2015; Cavalheri et al., 2011; Corrêa et al., 2011; Dechman and Scherer, 2008; Karloh

CONTACT Camila Isabel Santos Schivinski, PhD [email protected] Department of Physical Therapy, Santa Catarina State University, Florianópolis, Santa Catarina, Brasil. Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/iptp. © 2018 Taylor & Francis

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et al., 2014; Skumlien, Hagelund, Bjørtuft, and Ryg, 2006; Skumlien, Skogedal, Ryg, and Bjørtuft, 2008; Valadares et al., 2011), and none of them exclusively in children (Arikan et al., 2015). Thus, it is unknown how much time it would take a child to perform the TGlittre. It is also uncertain whether children would be able to understand and perform the test as accurately as adults. Ultimately, the physiological and metabolic changes imposed on children during this test are unknown. In summary, this study aimed to verify the validity and reliability of the TGlittre for children (TGlittre-P) in order to assess functional capacity in this population.

Methods This is an observational analytical cross-sectional study. A total of 87 healthy children aged 6–14 years participated in the research. They were recruited from private and public schools in the state of Santa Catarina, Brazil.The study was conducted from October 2012 to April 2014. The participants did not show any history of cardiac diseases; musculoskeletal, rheumatic and neurological disorders; or auditory and visual deficits. All children were physically active, as they attended physical education classes at school. Children who took part in intense training programs (e.g. athletes) and children considered obese by the World Health Organization (de Onis et al., 2007) were excluded. In addition, children who were unable to perform all procedures or failed to complete all tests were also excluded. All participants were informed of the nature of the study and volunteered to participate by presenting a Consent Form signed by a parent or guardian. This project was approved by the Research Ethics Committee of Santa Catarina State University (CAAE: 07635412.3.0000.0118). The International Study of Asthma and Allergies in Childhood (ISAAC) (Solé et al., 1998) questionnaire was applied as an exclusion criterion. In the 6- to 9year-old age group, children with scores greater or equal to five were diagnosed as having asthma and excluded from the study. As for the 10- to 14-year-old age group, children with scores of 6 or more were excluded from the study. The rhinitis module was performed (Vanna et al., 2001) only to characterize the participants with or without rhinitis. Other exclusion criteria were: 1) alteration in spirometry parameters including forced expiratory volume in the first second (FEV1); 2) forced vital capacity (FVC) of less than 80% of predicted; and 3) FEV1/FVC ratio less than 70%, according to Knudson, Slatin, Lebowitz, and Burrows (1976) and Polgar and Promadhat (1971). Spirometry

testing was performed without the use of a bronchodilator. After obtaining consent from the parent or guardian, biometric assessment (weight, height, body mass index [BMI] and lower limb [LL] length—measured between the anterior superior iliac spine and medial tibial malleolus) and spirometry tests (American Thoracic Society/ European Respiratory Society, 2005) (FEV1, FVC, and FEV1/FVC) were performed on all children. Measurements were taken with a stadiometer (Sanny®), a digital scale (Wiso® W903Ultra Slim), a measuring tape and a spirometer (EasyOne®). In the school environment, data was collected and all tests were administered individually by three examiners who had been previously trained on the collection procedures. Original TGlittre Protocol The original TGlittre (Skumlien, Hagelund, Bjørtuft, and Ryg, 2006) consists of completing a circuit while carrying a backpack with variable weight (2.5 kilograms [kg] for women, 5.0 kg for men—these weights are equivalent to the weight of a supplementary oxygen equipment). The following tasks should be carried out: from a sitting position, the individual stands up and walks along a 10m-long flat course, ascends and descends a 2-step rise (17 cm high x 27 cm wide) about half way along that distance and then walks the remaining 5 meters. At the end of the 10m course, the individual will reach a bookshelf with three objects weighing 1 kg each on the top shelf. The objects are placed on the top shelf at shoulder height, which should be removed, one by one, to the bottom shelf at waist height and then to the ground. Next, the objects should be returned to the bottom shelf and then back to the top shelf. The individual walks back along the same route, ascending and descending a 2-step rise to reach the final point (the chair), sits down and immediately starts the next lap. The individuals were instructed to complete five laps as quickly as possible. During the test, they received no verbal encouragement. Heart rate (HR), peripheral oxygen saturation (pSO2) (digital oximeter-Nonin Onyx® 9500), dyspnea index (Modified Borg Scale [American Thoracic Society, 2002]) were measured at the beginning, in each lap and the end of the test. Respiratory rate (RR) and blood pressure (BP) (sphygmomanometer and stethoscope-BIC®) were measured only at the beginning and the end of the test. TGlittre-P In our study, the TGlittre-P (Figure 1) went through minor changes from the original test. These changes

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Figure 1. Representation of ADL-Glittre test adapted for children (TGlittre-P).

Table 1. Weight of the backpack according to children’s age and gender. Male Age/Weight (kg) 6 years ≤ 20.7 kg 6–9 years 10 years ≤ 31.4 kg 10–11 years 11 years ≤ 35.3 kg 12–13 years 14 years ≤ 50.8 kg 14 years > 50.8 kg

At the beginning and at the end of the test, the children were examined for BP and RR while seated.

Female Backpack’s weight (kg) 0.5 kg 1.0 kg 1.0 kg 1.5 kg 1.5 kg 2.0 kg 2.0 kg 2.5 kg

Age/Weight (kg) 6 years ≤ 19.5 kg 6–9 years 10 years ≤ 32.5 kg 10–11 years 11 years ≤ 37.0 kg 12–13 years 14 years ≤ 50.3 kg 14 years > 50.3 kg

Backpack’s weight (kg) 0.5 kg 1.0 kg 1.0 kg 1.5 kg 1.5 kg 2.0 kg 2.0 kg 2.5 kg

kg: kilograms. Source: prepared by the researchers based on World Health Organization chart for height and weight in females and males (1995).

are described as follows: 1) the backpack weight was changed to 0.5–2.5 kg, depending on the children’s weight (Table 1) (to determine the backpack weight of each child, the value of 5% of the minimum weight for each age included in the study was calculated, based on World Health Organization (1995) weight and height values); 2) the objects were placed on the shelves at different heights from the original test due to the smaller stature of the child; the top shelf was at eye level and the bottom shelf was at the level of the umbilicus; 3) the weight of the objects was changed from 1 kg to 0.5 kg; 4) colored bowling pins filled with sand were introduced to allow children to familiarize with the testing procedures; and 5) verbal stimuli (“sit and stand up”) were used to guide the children in each lap and to prevent them from rushing to finish the test and, therefore, skipping a task (i.e. sitting on the chair). The children were considered able to stand up and perform the next lap after they had sat down in the bottom of the chair with their back against the back of the chair. In regard to sitting, the chair height should ensure that the feet or at least the tip of the child´s toes touched the floor. As in the original test, children were monitored during the modified test. Heart rate, pSO2, and the dyspnea index (Modified Borg Scale [American Thoracic Society, 2002]) were measured at the beginning of the test, for each lap, and at the end of the test.

6-minute walk test Part of the sample size performed two 6MWT with a 30-minute interval between them. The 6MWT was performed according to the American Thoracic Society (2002) guidelines. HR, pSO2, and the dyspnea index (Modified Borg Scale [American Thoracic Society, 2002]) were assessed at the beginning, second minute, fourth minute, and sixth minute of the test. BP and RR were assessed only at the beginning and at the end of the test. Validity and reliability For the validity of the TGlittre-P, part of the sample size (36 children) performed the 6MWT and the TGlittre-P twice, with a 30-minute interval between them. The children remained at rest during this time interval. The recovery time was considered long enough to allow the cardiorespiratory parameters to return to baseline values. All tests were administered on the same day by the same three examiners, who had received training on the collection procedures. The TGlittre-P and 6MWT were always performed by the same examiners, with only one test conducted at a time. First, the 6MWT was performed, then the TGlittre-P. This test sequence was chosen because the 6MWT is a well-established self-paced test in the pediatric population. As the 6MWT involves just walking, it could facilitate the familiarization of the children with the monitoring of the cardiorespiratory parameters during the tests. Before the children started the evaluation, each task was demonstrated by the examiner. Sample size calculation According to Bonett (2002) and Fleiss (1999), 15 to 20 subjects would be required to estimate reliability in a

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test. However, as the present study is part of a research that developed reference equations for TGlittre-P, the data from a prior pilot study (n = 10 children) were used to calculate the sample size, assuming that this method would be more appropriate. Conventional practice is to determine the sample size that gives 80% power at the 0.05 level of significance (twosided) with the intention of determining the CI of 95% of the mean (Hair, Anderson, Tathan, and Black, 2005). Moreover, in order to determine an appropriate sample size, an acceptable margin of error d (delta) should be determined first. The TGlittre-P SD values from this pilot study was seconds and a delta (Δ) of 3 sec was considered. Therefore, for the present study, a sample size of 40 children of each gender was considered large enough. Statistics For statistical analyses, the children were divided into two groups. One group was formed by children who underwent the tests for the validity study, and the other group for the reliability study. The statistical analyses were performed using SPSS Version 20.0 statistic software package. Descriptive statistics (mean, standard deviation, and frequencies) were calculated for all variables. The Shapiro– Wilk (for the validity sample) and the Kolmogorov– Smirnov (for the reliability sample) tests were used to determine normality of the data. Wilcoxon test analyses were used to examine differences between initial and final parameters in the 6MWT and TGlittre-P best performances. For the validity of the study, Pearson’s correlation was used to analyze correlations between the second TGlittre-P and first and second 6MWT, best performance TGlittre-P and best performance 6MWT. The Spearman’s correlation was used to analyze correlations between the first TGlittre-P and first and second 6MWT. The Intraclass Correlation Coefficient (ICC3,1) was used to check the

reproducibility of the TGlittre-P. These results were interpreted according to the classification system proposed by Portney and Watkins (2009). The authors suggested that ICCs greater than 0.75 represent good reliability and ICCs less than 0.75 reflect moderate to poor reliability, depending on the magnitude. The Bland–Altman plot was also used to analyze reproducibility in order to allow better visualization of the correlations between individual measurements. The statistical significance was set at p < 0.05.

Results A total of 185 children were identified for the study, 98 of whom were excluded. Sixty-five children did not perform spirometry adequately or the FEV1 or FVC was less than 80% of predicted for their age, sex, weight, and height. Twelve children were diagnosed with some kind of respiratory disease. Three children scored higher than the cutoff point defined by the ISAAC questionnaire in the asthma module. Thirteen children were considered obese. Three children did not want to finish the tests. One child was not born in Brazil. The performance of one child was affected by equipment failure (spirometer). A total of 87 children participated in the study, of whom 36 (41.37% of the sample) took part in the TGlittre-P validation process. The characteristics of the children are shown in Tables 2 and 3. The relationship between the distance walked in the 6MWT and the time spent on TGlittre-P is shown in Table 4. The initial and final values of HR, RR, pSO2, BP, dyspnea index during 6MWT and TGlittre-P best performance are shown in Table 5. The initial parameters in both best performance tests were compared and a significant difference was observed only in diastolic BP (p = 0.047). For the validity of the TGlittre-P, variations in HR, RR, pSO2, BP, and dyspnea indexes were also analyzed. Parameters, such as HR, RR, pSO2, BP, showed no

Table 2. Characterization of the sample with presentation of frequency data. AV Variable Gender Ethnicity Prematurity Passive smoking Rhinitis*

Female Male Caucasian Black Brown Yes No Not informed Yes No Yes No

Validity (n = 36) 18 18 24 6 6 3 33 0 16 20 9 27

% Reliability (n = 87) 44 43 58 15 14 8 77 2 27 60 23 64

Validity 50.0 50.0 66.7 16.7 16.7 8.3 91.7 0.0 44.4 55.6 25.0 75.0

Reliability 50.6 49.4 66.7 17.2 16.1 9.2 88.5 2.3 31.0 69.0 26.4 73.6

AV: absolute value; n: total number of children; %: percentage; * characterization of rhinitis by the International Study of Asthma and Allergies in Childhood questionnaire (ISAAC).

PHYSIOTHERAPY THEORY AND PRACTICE

Table 3. Characterization of the sample with presentation of descriptive data and tests performance. Mean±SD Age (years) Weight (kg) Height (m) BMI (kg/m2) LLR (cm) LLL (cm) FEV1 (%) FVC (%) FEV1/FCV (%) FEF 25–75 (%) PEF (%) ISAAC–asthma ISAAC–rhinitis 6MWT 1(m) 6MWT 2 (m) B–6MWT (m) TGlittre-P 1 (sec) TGlittre-P 2 (sec) B–TGlittre-P (sec)

Validity (n = 36) 10.00 ± 2.61 37.09 ± 11.07 1.41 ± 0.13 18.06 ± 2.44 76.25 ± 8.87 76.41 ± 8.96 92.69 ± 8.77 97.78 ± 8.77 86.44 ± 5.49 91.50 ± 24.12 81.72 ± 14.71 1.11 ± 1.67 2.25 ± 3.41 554.11 ± 89.74 568.40 ± 88.20 583.76 ± 87.54 183.6 ± 34.2 170.4 ± 24.6 169.8 ± 25.2

Reliability (n = 87) 10.36 ± 2.32 38.48 ± 11.42 1.43 ± 0.13 18.33 ± 2.79 77.72 ± 8.74 77.82 ± 8.74 92.40 ± 8.77 98.68 ± 9.58 86.53 ± 6.40 89.66 ± 20.69 82.38 ± 13.78 1.03 ± 1.52 2.40 ± 3.64 ------------180.0 ± 30.0 170.4 ± 24.6 168.6 ± 24.0

B: best performance test; BMI: body mass index; cm: centimeters; 6MWT: distance walked in six- minute walk test; FEF: forced expiratory flow between 25 and 75% of FVC; FEV1: forced expiratory volume in the first second; FVC: forced vital capacity; ISAAC: International Study of Asthma and Allergies in Childhood questionnaire score; kg: kilograms; LLL: measurement of the length of the left leg; LLR: measurement of the length of the right leg; m: meters; m2: square meter; n: total number of children; PEF: peak expiratory flow; SD: standard deviation; sec: seconds; TGlittre-P: time spent in the ADL-Glittre test adapted for children; %: percentage of predicted value.

Table 4. Correlations between six-minute walk test and ADL-Glittre test adapted for children.

6MWT 1 x TGlittre-P 1 6MWT 2 x TGlittre-P 2 6MWT 1 x TGlittre-P 2 6MWT 2 x TGlittre-P 1 B −6MWT x B-TGlittre-P

Correlation coefficient −0.385 −0.530 −0.453 −0.448 −0.490

p-Value (n = 36) 0.021* 0.001* 0.005* 0.006* 0.002*

95%CI −0.659 a −0.050 −0.752 a −0.267 −0.705 a −0.183 −0.687 a −0.109 −0.712 a −0.233

Note: B: best performance test; CI: confidence interval; 6MWT 1 and 2: distance walked in the first and second six-minute walk tests; n: total number of children; TGlittre-P 1 and 2: first and second ADL-Glittre tests adapted for children; * p < 0.05.

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significant differences between initial and final scores, with the exception of the dyspnea index in the 6MWT (p = 0.048; 95% CI 0.037 to 0.045). Additionally, differences in HR, RR, pSO2, BP, and dyspnea index were evaluated between the beginning and the end of the tests. A significant change was found after both performance tests (6MWT and TGlittre-P), except for pSO2 (p = 0.121, 95% CI 0.162 to 0.176) and diastolic BP (p = 0.950, 95% CI 0.984 to 0.988), both in the 6MWT. Regarding reproducibility, a strong correlation (ICC = 0.843, p = 0.000, 95% CI 0.695 to 0.911) could be observed between the time spent on the first and second TGlittre-P, showed in the Bland and Altman plot (Figure 2).

Discussion This was the first study to propose an adaptation to the TGlittre for children (Figure 1), as well as to verify the validity and reliability of this test, which could be confirmed in this study population. Child development is characterized by continuous changes in the body. These changes are both physical and psychosocial, and can influence physical activities and weight support. For this reason, children should do age-appropriate activities. Their natural patterns of movement differ from those of adults (Malina, Bouchard, and Bar-Or, 2004). Thus, the TGlittre for adults was adapted to evaluate ADL in children. In order to capture children’s attention, the TGlittre was adapted to more playful and attractive tasks. One of the adaptations was the use of colored bowling pins filled with sand, instead of common and simple objects. Another adaptation was placing the objects according to the children´s height. Ultimately, the backpack load and the weight of the objects were changed to reflect the various stages of development of the children (both physical and mental) as well as gains

Table 5. Descriptive data of the parameters of best tests and results of comparison between them. Mean±SD HR initial (bpm) HR final (bpm) RR initial (rpm) RR final (rpm) pSO2 initial (%) pSO2 final (%) SBP initial (mmHg) SBP final (mmHg) DBP initial (mmHg) DBP final (mmHg) BORG initial BORG final

6MWT (n 81.50 ± 118.78 ± 19.67 ± 25.83 ± 98.92 ± 98.69 ± 97.92 ± 103.89 ± 62.92 ± 63.06 ± 0.00 ± 0.33 ±

= 36) 10.39 23.02 3.32 4.33 0.28 0.82 9.05 9.42 9.81 9.12 0.00 0.64

TGlittre-P (n = 36) 82.00 ± 11.81 124.25 ± 20.28 20.53 ± 3.02 26.64 ± 3.55 98.83 ± 0.60 98.44 ± 1.15 96.81 ± 9.27 104.17 ± 11.18 59.72 ± 8.27 64.58 ± 9.36 0.00 ± 0.00 0.25 ± 0.86

p-Value 0.179

95%CI 0.171 to 0.186

0.971

0.971 to 0.977

0.783

0.839 to 0.853

0.163

0.161 to 0.175

0.761

0.787 to 0.803

0.071

0.065 to 0.075

BORG: dyspnea index score on the modified Borg scale; bpm: beats per minute; CI: confidence interval; DBP: diastolic blood pressure; HR: heart rate; mmHg: millimeters of mercury; n: total number of children; rpm: respirations per minute; pSO2: peripheral oxygen saturation; RR: respiratory rate; SBP: systolic blood pressure; SD: standard deviation; TGlittre-P: ADL-Glittre test adapted for children; 6MWT: six-minute walk test.

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Figure 2. Distribution of individual differences and individual averages between the times spent in the two TGlittre-P.

in muscular strength (Malina, Bouchard, and Bar-Or, 2004). These adaptations of the TGlittre showed satisfactory results, as all children seemed to be fully engaged, showing great enthusiasm during the test. In addition, the tasks were performed accordingly by all children. A comparison between the TGlittre-P and the 6MWT was performed with the goal of verifying the validity of the former. Admittedly, the 6MWT is classified as a submaximal test and most ADL represent submaximal levels of exercise (Pitta et al., 2005). In adults, the metabolic, ventilatory, and cardiovascular responses generated by the TGlittre are similar to those induced by the 6MWT (Karloh et al., 2014), which indicates that these tests are comparable. There was a moderate negative correlation between the time spent on the TGlittre-P and the distance walked in the 6MWT. The 6MWT is a submaximal exercise test used to assess functional exercise capacity in the adult and pediatric populations (Geiger et al., 2007; Pitta et al., 2005; Solway, Brooks, Lacasse, and Thomas, 2001). However, the use of 6MWT in pediatric populations is often questioned, since parameters, such as growth spurt and puberty, may influence the results. Furthermore, the walking speed and stride length might affect the subjects’ performance (Martins, Gonçalves, Mayer, and Schivinski, 2014; Okuro and Schivinski, 2013). The comparison between the initial and final cardiorespiratory parameters in the 6MWT and TGlittre-P showed similar variation in both tests. This finding confirms that the systemic demand is similar in both 6MWT and TGlittre-P, as it is observed in adults (Karloh et al., 2014). The dyspnea index variation value was the only variable that showed significant difference between the 6MWT and the TGlittre-P, greater in the 6MWT.

As the 6MWT just involves walking at a constant speed, the test performance can become monotonous for children. Differently, the TGlittre-P is more dynamic, playful and with a greater variety of activities and speeds, such as stopping, sitting down, standing up, going up and downstairs. Thus, is important to note that children´s motivation to practice physical activities can be affected when children are forced to do something they do not want to (Ryan and Deci, 2006). Additionally, as observed in Table 3, the mean time to perform the TGlittre-P was 2.83min (170sec), showing that it requires less time than the 6MWT. Although the TGlittre-P shows advantages, some disadvantages can be pointed out. It requires more resources, such as backpack, chair, specific stairs, shelves and objects. The TGlittre-P also needs more preparation time to set up the circuit and check the weight of the child, as well as staff with specific training for the test administration, as also required for the 6MWT. In this sense, the 6MWT is more practical and simple to perform. However, it may not keep much of children’s attention, leaving them unmotivated. According to the literature, testing children through playful tests improves physical activities evaluations (Gao, Podlog, and Huang, 2013). Possibly, these characteristics make the TGlittre-P more interesting when testing children, since they feel less worried about the duration and the monotony of the test. Some limitations of this study have been identified and should be highlighted. Firstly, the sample size was limited due to the children’s difficulty in understanding the spirometry test. Six-year-olds are considered to be able to perform spirometry tests. However, these children must have high levels of comprehension, concentration and cooperation (American Thoracic Society/European Respiratory Society, 2005) to perform successful spirometry maneuvers and to meet the acceptability and repeatability criteria. Secondly, getting and keeping children´s attention during the test was a challenging task, especially during the intervals. It was rather difficult to keep them at rest until the cardiorespiratory parameters returned to baseline values. This was very evident during the intervals between the tests, as it took approximately two and half hours to perform all the tests (two 6MWT and two TGlittre-P). Finally, another limitation was the lack of analysis of the metabolic and ventilatory response, which could deepen the comparison between the two tests performed in children. In conclusion, the ADL-Glittre test adapted for children is shown to be a valid and reliable assessment of the functional capacity of healthy children aged

PHYSIOTHERAPY THEORY AND PRACTICE

6–14 years. This test may contribute to assess the effectiveness of diverse therapies in children with different chronic diseases. However, further studies investigating the TGlittre-P impacts and importance in the pediatric population with pulmonary diseases should be conducted.

Acknowledgments The authors gratefully thank all members of the research group from University of the State of Santa Catarina— Brazil (UDESC), “Núcleo de Fisioterapia em Pneumologia Pediátrica” (NuFiPP) for their collaboration and support during data collection, as well as the school management teams for their consent for data collection.

Declaration of Interest The authors have no conflicts of interest to disclose.

Funding This study was supported by the FUMDES/Government of the State of Santa Catarina.

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