OBJECTIVES: To examine the relevance and completeness of the comprehensive International Classification of Functioning, Disability and Health (ICF) Core Sets for patients in post-acute rehabilitation facilities.
DESIGN: Multi-centre cohort study.
Patients: A total of 165 patients (46% female; mean age 67.5 years) from post-acute rehabilitation facilities in 2 Austrian and 7 German hospitals.
METHODS: Data on functioning were collected using the respective comprehensive post-acute ICF Core Sets. Data was extracted from patients’ medical record sheets and interviews with health professionals and patients.
RESULTS: Most of the categories of the comprehensive ICF Core Sets describing impairments, limitations or restrictions occurred in a considerable proportion of the study population. The most outstanding limitations and restrictions of the patients were problems with sleep and blood vessel functions, walking and moving and self-care. Twenty-six aspects of functioning not previously covered by the comprehensive ICF Core Sets were ranked as relevant.
CONCLUSION: Most categories of the comprehensive ICF Core Set for patients in post-acute rehabilitation facilities were confirmed. No significant gaps in the established set could be identified.
Key words: ICF; cohort study; rehabilitation; outcome assessment; classification.
J Rehabil Med 2011; 43: 102–112
Correspondence address: Eva Grill, Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians-Universität München, DE-81377 Munich, Germany. E-mail: eva.grill@med.uni-muenchen.de
Submitted May 25, 2010; accepted November 18, 2010
Introduction
Human functioning and its contrary notion, disability, are universal experiences, which must be understood in the context of an individual’s personal resources, particular health conditions and expectations, and in interaction with the environment (1). Any acute injury or disease may have the consequence of bringing about transient or permanent disability. Thus, post-acute rehabilitation has the goal of optimizing functioning of people experiencing, or at risk of experiencing, disability. In situations entailing post-acute and long-term rehabilitation, professionals specialized in rehabilitation management should share a common understanding of functioning, and should utilize clinical assessment instruments that are based on a standard model of functioning.
The International Classification of Functioning, Disability and Health (ICF) (2), as a part of the World Health Organization’s international family of classifications, is the contemporary framework to harmonize the assessment of functioning and disability at the individual and the societal level. The ICF covers all domains of human functioning and relating contextual factors. Since the ICF was developed as a multipurpose classification for various user groups it has to be comprehensive by its very nature. This comprehensiveness, which results in more than 1,400 categories, is the major challenge for implementing the ICF in daily practice. To foster the implementation of the ICF in clinical practice and research, the development of shorter practical tools is needed. The development of such tools for specific care situations or health conditions was the primary motivation behind the ICF Core Set project. The ICF Core Set project aimed to define so-called comprehensive ICF Core Sets which should define commonly acceptable standards for what aspects of functioning and disability should properly be measured and reported.
The development process of comprehensive ICF Core Sets involved evidence from different sources: the patients’ perspective, the health professionals’ perspective, the perspective of research and the actual prevalence in clinical practice. These perspectives were summarized and adopted in a formalized consensus process (3). Comprehensive ICF Core Sets for post-acute rehabilitation facilities have already been developed for patients with neurological, cardiopulmonary and musculoskeletal conditions (4–6).
Comprehensive ICF Core Sets can be used for the assessment of problems and needs, as well as for the estimation of prognosis and rehabilitation potential. Similarly, they can be used to coordinate rehabilitation interventions and strategies and to define rehabilitation goals. Finally, the Sets are envisioned to serve as a list of candidate categories for creating new specific measurement instruments customized for the needs of the respective user.
The validation of comprehensive ICF Core Sets tailored for the use in particular contexts, needs an adequate methodological framework. The ICF Core Set project adopted the concept used in the Outcome Measures in Rheumatology (OMERACT) project. OMERACT identified 3 different properties relevant to the applicability of measures, namely truth, discrimination and feasibility (4). The criteria truth and discrimination can be applied to test the validity of the comprehensive sets. Truth refers to the question of what should properly be measured. As noted above, the original process for generating the comprehensive ICF Core Set had assured that all the relevant aspects of functioning were included, but the empirical validation of the choice of categories remains to be completed. The criterion discrimination refers to the ability of a measure to discriminate between different states of functioning or medical conditions. A discriminating measure must distinguish between different patient groups in a cross-sectional manner, and assess change of relevant aspects over time.
The objective of this study was to examine the relevance and completeness of the comprehensive ICF Core Sets for post-acute rehabilitation facilities. Specifically, we wanted to examine which aspects of functioning included in the comprehensive post-acute ICF Core Sets were frequent at admission to, and at discharge from, inpatient rehabilitation, and which aspects changed during hospital stay. We also searched for novel aspects that might be relevant for inclusion in the revised Set.
Methods
Study design
A full description of the methods used in this study has been reported elsewhere (5). In brief, the study design was a prospective multi-centre cohort study conducted from May 2005 to August 2008. The study population was recruited from post-acute rehabilitation facilities in 2 Austrian and 7 German hospitals, with approximately 9% of the patients being recruited from the Austrian centres. Patients were eligible if they were at least 18 years of age and experienced a recent acute episode of musculoskeletal, neurological, or cardiopulmonary injury or disease. Patients had to receive coordinated rehabilitation interventions by a multidisciplinary team and required ongoing need for nursing and medical care. Written informed consent was obtained from the patients or from the patient’s care-giver in cases where the patient was unable to make an informed decision. Approval was obtained from institutional ethics committees from all involved institutions prior to starting the study.
Measures
For the assessment of functioning, we used the 3 comprehensive ICF Core Sets for patients in the post-acute rehabilitation situation, which were earlier developed to address the specific situations of patients with neurological, musculoskeletal, or cardiopulmonary conditions (4–6). For all patients, impairments in categories of the component Body Structures were graded as present or absent. Limitations or restrictions in categories of the components Body Functions and Activities and Participation were graded as “none”, “slight/moderate/severe” or “complete” limitation or restriction. The categories of the component Environmental Factors were graded either as facilitator or barrier, or both. Change in the components Body Functions, Body Structures and Activities and Participation was defined as any change between the 3 recorded measures (none, slight/moderate/severe or complete), irrespective of the direction of the change.
We elected to report only those impairments, limitations and restrictions directly associated with the conditions causing the need for rehabilitation. The interviewers judged which of the impairments, limitations or restrictions resulted from the referring condition or principal diagnosis, and which occurred as a result of a specific co-morbidity. In order to validate the completeness of the comprehensive ICF Core Sets, the interviewers were furthermore asked to identify any aspects of functioning relevant to the patient, but not currently covered by the comprehensive ICF Core Sets. Additionally, socio-demographic (sex, age, education, living and occupation situation) and condition-specific data (underlying diagnosis, time until rehabilitation, number of co-morbidities and length of stay) were recorded.
Data collection procedures
Data were primarily collected from patients’ medical record sheets, health professionals in charge of the patients, and from patients’ interviews. Interviewers collecting data had been trained in the application and principles of the ICF, and provided with a manual. All interviewers were health professionals (physicians, medical students in clinical training, physical therapists, or nurses). During data collection interviewers obtained support and information from the ward staff in charge. Their ongoing supervision was ensured by periodic telephone calls.
Data collection took place within the first 24 h after admission to the hospital (baseline) and within the last 36 hours before discharge or, if length of stay was longer than 6 weeks, at 6 weeks after admission (end-point). ICF categories from the component Environmental Factors were assessed only at admission, since we did not expect any change in these categories during hospital stay.
Statistical analysis
For the categories of the ICF components Body Functions, Body Structures and Activities and Participation we calculated the absolute and relative frequencies (prevalences) of impairment, limitation or restriction at baseline and end-point. For the categories of the ICF component Environmental factors, we calculated the absolute and relative frequencies (prevalences) of persons who regarded a specific category as constituting either a barrier or facilitator. Relative frequencies of persons for whom the ICF category changed during the study period were calculated, along with their 95% confidence intervals (CI).
Aspects of functioning not covered by the comprehensive ICF Core Sets, but identified as relevant, were extracted and translated into the best corresponding ICF category. Absolute and relative frequencies of occurrence of those ICF categories were reported; any such category with prevalence below 5% was considered as not relevant.
Results
Sociodemographic data
In total, 165 patients were included. Mean age at admission was 67.5 years (median 69.2; standard deviation (SD) 14.8 years). Mean length of stay was 14.9 days (median 10; SD 13.7 days). Forty-six percent of the patients were female (95% CI: 39–54). Sixty-seven had a neurological, 37 a cardiopulmonary and 61 a musculoskeletal condition. No patients were lost to follow-up. The most frequent admission diagnoses classified according ICD-10 in patients with neurological conditions were “Cerebrovascular diseases” (n = 27; 40.3%) and “Diseases
of the nervous system”, (most prominently inflammatory polyneuropathies) (n = 22, 32.8%). The most frequent admission diagnoses in patients with cardiopulmonary conditions were “Diseases of the circulatory system (n = 27; 73.0%) and “Dyspnea” (n = 7, 18.9%) from “Symptoms and signs involving the circulatory and respiratory systems”. The most frequent admission diagnoses in patients with musculoskeletal conditions were “Diseases of the musculoskeletal system and connective tissue” (mainly disc disorders) (n = 14; 23.0%) and fractures of the upper or lower extremities, or hip (n = 19, 31.1%). For further socio-demographic and condition-related variables see Table I.
| Table I. Characteristics of participants |
| Variable | All
conditions | Neurological conditions | Cardiopulmonary conditions | Musculoskeletal conditions |
| Number of participants, n | 165 | 67 | 37 | 61 |
| Age, years, mean (SD) | 67.5 (14.8) | 63.9 (15.2) | 78.3 (8.9) | 64.8 (14.4) |
| Comorbidities, mean (SD) | 3.1 (2.4) | 2.5 (1.9) | 4.9 (2.5) | 2.8 (2.2) |
| Length of stay, days, mean (SD) | 30.5 (18.1) | 34.2 (19.9) | 23.7 (14.5) | 30.6 (17.1) |
| Time from event to rehabilitation onset, days, mean (median) | 29.6 (17.0) | 28.6 (14.5) | 25.7 (13.0) | 33.1 (22.5) |
| Female gender, % | 46.1 | 35.8 | 54.1 | 52.5 |
| Diagnosis, n (%) | | | | |
| Diseases of the respiratory system (J00-J99) | 1 (0.6) | 1 (1.5) | 0 (0) | 0 (0) |
| Diseases of the circulatory system other than cerebrovascular diseases
(I00-I52 and I70-I99) | 34 (20.6) | 2 (3.0) | 27 (73.0) | 5 (8.2) |
| Cerebrovascular diseases (I60-I69) | 27 (16.4) | 27 (40.3) | 0 (0) | 0 (0) |
| Diseases of the nervous system (G00-G99) | 25 (15.2) | 22 (32.8) | 0 (0) | 3 (4.9) |
| Diseases of the musculoskeletal system and connective tissue (M00-M99) | 25 (15.2) | 10 (14.9) | 1 (2.7) | 14 (23.0) |
| Injury, poisoning and certain other consequences of external causes (S00-T98) | 24 (14.5) | 0 (0) | 0 (0) | 24 (39.3) |
| Neoplasms (C00-D48) | 6 (3.6) | 2 (3.0) | 1 (2.7) | 3 (4.9) |
| Other diagnoses | 23 (13.9) | 3 (4.5) | 8 (21.6) | 12 (19.7) |
| SD: standard deviation. |
Functioning and disability
Tables II–IV give the prevalence of impairment or restriction, both at admission and discharge, as well as the corresponding 95% CI:s for the frequency of change in impairment or restriction, for each category of underlying condition.
| Table II. International Classification of Functioning, Disability and Health (ICF) categories of the component Body Functions – percentage of participants with impairment at admission/discharge and the extent of change over time |
| ICF | ICF Code Description | Neurological conditions n = 67 | Cardiopulmonary conditions n = 37 | Musculoskeletal conditions n = 61 |
| Admission | Discharge | Change | Admission | Discharge | Change | Admission | Discharge | Change |
| na | %b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c |
| b110 | Consciousness functions | 66 | 47 | 67 | 36 | 12 (5–22) | 37 | 5 | 37 | 0 | 5 (1–18) | | | | | |
| b114 | Orientation functions | 65 | 45 | 67 | 33 | 15 (8–26) | 37 | 19 | 37 | 14 | 8 (2–22) | | | | | |
| b126 | Temperament and personality functions | 61 | 56 | 66 | 44 | 15 (7–27) | | | | | | | | | | |
| b130 | Energy and drive functions | 63 | 76 | 66 | 64 | 15 (7–26) | 37 | 27 | 37 | 19 | 19 (8–35) | 61 | 46 | 60 | 32 | 15 (7–27) |
| b134 | Sleep functions | 66 | 62 | 67 | 48 | 24 (15–36) | 37 | 46 | 37 | 30 | 32 (18–50) | 61 | 54 | 61 | 33 | 28 (17–41) |
| b140 | Attention functions | 66 | 56 | 67 | 42 | 24 (15–36) | 37 | 16 | 37 | 11 | 16 (6–32) | | | | | |
| b144 | Memory functions | 63 | 54 | 66 | 48 | 11 (5–22) | 37 | 14 | 37 | 16 | 3 (0–14) | | | | | |
| b147 | Psychomotor functions | 60 | 62 | 67 | 46 | 17 (8–29) | | | | | | | | | | |
| b152 | Emotional functions | 63 | 63 | 66 | 52 | 22 (13–34) | 37 | 16 | 36 | 8 | 11 (3–26) | 58 | 47 | 61 | 31 | 21 (11–33) |
| b156 | Perceptual functions | 65 | 68 | 67 | 61 | 17 (9–28) | | | | | | | | | | |
| b160 | Thought functions | 63 | 41 | 65 | 40 | 10 (4–20) | | | | | | | | | | |
| b164 | Higher-level cognitive functions | 62 | 56 | 66 | 53 | 8 (3–18) | | | | | | | | | | |
| b167 | Mental functions of language | 66 | 39 | 67 | 36 | 12 (5–22) | | | | | | | | | | |
| b176 | Mental function of sequencing complex movements | 64 | 59 | 67 | 54 | 14 (7–25) | | | | | | | | | | |
| b180 | Experience of self and time functions | 65 | 54 | 67 | 46 | 12 (5–23) | | | | | | | | | | |
| b210 | Seeing functions | 63 | 16 | 67 | 15 | 3 (0–11) | | | | | | | | | | |
| b215 | Function of structures adjoining the eye | 63 | 11 | 66 | 11 | 3 (0–11) | | | | | | | | | | |
| b230 | Hearing functions | 65 | 9 | 67 | 12 | 3 (0–11) | | | | | | | | | | |
| b235 | Vestibular functions | 63 | 24 | 67 | 24 | 19 (10–31) | | | | | | | | | | |
| b240 | Sensations associated with hearing and vestibular function | 62 | 26 | 66 | 21 | 18 (9–30) | | | | | | | | | | |
| b260 | Proprioceptive function | 67 | 90 | 67 | 85 | 19 (11–31) | 36 | 14 | 37 | 11 | 6 (1–19) | 61 | 67 | 61 | 52 | 25 (14–37) |
| b265 | Touch function | 66 | 64 | 67 | 58 | 15 (8–26) | | | | | | | | | | |
| b270 | Sensory functions related to temperature and other stimuli | 63 | 57 | 67 | 54 | 25 (15–38) | | | | | | 52 | 40 | 52 | 27 | 21 (11–35) |
| b280 | Sensation of pain | 67 | 64 | 67 | 54 | 24 (14–36) | 37 | 46 | 34 | 35 | 26 (13–44) | 60 | 75 | 61 | 59 | 32 (20–45) |
| b310 | Voice functions | 65 | 51 | 66 | 38 | 18 (10–30) | 6 | 67 | 6 | 17 | 67 (22–96) | | | | | |
| b320 | Articulation functions | 65 | 43 | 67 | 37 | 17 (9–28) | | | | | | | | | | |
| b340 | Alternative vocalization functions | 65 | 38 | 66 | 27 | 15 (8–26) | | | | | | | | | | |
| b410 | Heart functions | 60 | 35 | 67 | 36 | 5 (1–14) | 37 | 81 | 36 | 81 | 25 (12–42) | | | | | |
| b415 | Blood vessel functions | 64 | 69 | 67 | 60 | 19 (10–30) | 37 | 68 | 36 | 53 | 19 (8–36) | 57 | 49 | 61 | 41 | 14 (6–26) |
| b420 | Blood pressure functions | 66 | 48 | 67 | 45 | 17 (9–28) | 37 | 62 | 37 | 62 | 14 (5–29) | | | | | |
| b430 | Haematological system functions | 66 | 38 | 67 | 30 | 18 (10–30) | 35 | 37 | 36 | 28 | 18 (7–35) | | | | | |
| b435 | Immunological system functions | 67 | 49 | 67 | 39 | 1 (7–26) | 33 | 18 | 35 | 11 | 3 (0–16) | 48 | 38 | 50 | 30 | 15 (6–28) |
| b440 | Respiration functions | 67 | 42 | 67 | 22 | 27 (17–39) | 36 | 64 | 36 | 44 | 26 (12–43) | 61 | 20 | 61 | 10 | 13 (6–24) |
| b445 | Respiratory muscle functions | | | | | | 6 | 83 | 6 | 50 | 33 (4–78) | | | | | |
| b450 | Additional respiratory functions | 66 | 29 | 67 | 16 | 17 (9–28) | 35 | 29 | 35 | 23 | 18 (7–35) | | | | | |
| b455 | Exercise tolerance functions | 66 | 77 | 67 | 75 | 8 (3–17) | 37 | 92 | 37 | 86 | 22 (10–38) | 58 | 64 | 60 | 52 | 21 (11–33) |
| b460 | Sensations associated with cardiovascular and respiratory functions | | | | | | 35 | 77 | 36 | 67 | 21 (9–38) | | | | | |
| b510 | Ingestion functions | 66 | 47 | 67 | 33 | 29 (18–41) | 37 | 19 | 37 | 14 | 14 (5–29) | | | | | |
| b515 | Digestive functions | 65 | 48 | 67 | 37 | 25 (15–37) | | | | | | | | | | |
| b525 | Defecation functions | 66 | 61 | 67 | 45 | 26 (16–38) | 37 | 14 | 36 | 8 | 11 (3–26) | 61 | 18 | 61 | 13 | 13 (6–24) |
| b530 | Weight maintenance functions | 63 | 59 | 67 | 46 | 27 (17–40) | 32 | 25 | 35 | 23 | 6 (1–21) | 46 | 28 | 52 | 13 | 26 (14–41) |
| b535 | Sensations associated with the digestive system | 59 | 29 | 63 | 27 | 20 (11–33) | | | | | | | | | | |
| b540 | General metabolic functions | 66 | 36 | 67 | 27 | 12 (5–22) | | | | | | | | | | |
| b545 | Water, mineral and electrolyte balance functions | 66 | 59 | 67 | 49 | 20 (11–31) | 34 | 26 | 34 | 12 | 24 (11–42) | | | | | |
| b550 | Thermoregulatory functions | 65 | 17 | 67 | 13 | 12 (5–23) | | | | | | | | | | |
| b610 | Urinary excretory functions | | | | | | 6 | 50 | 6 | 0 | 50 (12–88) | | | | | |
| Table II contd. |
| ICF | ICF Code Description | Neurological conditions n = 67 | Cardiopulmonary conditions n = 37 | Musculoskeletal conditions n = 61 |
| Admission | Discharge | Change | Admission | Discharge | Change | Admission | Discharge | Change |
| n1 | %2 | na | %b | % (CI)c | na | %b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c |
| b620 | Urination functions | 67 | 57 | 67 | 46 | 27 (17–39) | 37 | 19 | 37 | 5 | 16 (6–32) | 60 | 20 | 60 | 13 | 10 (4–21) |
| b630 | Sensations associated with urinary functions | 59 | 51 | 61 | 36 | 25 (15–38) | | | | | | | | | | |
| b710 | Mobility of joint functions | 67 | 81 | 67 | 73 | 16 (8–27) | 37 | 49 | 37 | 32 | 19 (8–35) | 61 | 92 | 61 | 92 | 13 (6–24) |
| b715 | Stability of joint functions | 67 | 64 | 67 | 49 | 24 (14–36) | | | | | | 61 | 69 | 61 | 66 | 23 (13–35) |
| b730 | Muscle power functions | 67 | 97 | 67 | 97 | 6 (2–15) | 37 | 68 | 37 | 51 | 22 (10–38) | 61 | 95 | 61 | 92 | 8 (3–18) |
| b735 | Muscle tone functions | 67 | 88 | 67 | 75 | 18 (10–29) | | | | | | 61 | 66 | 61 | 57 | 16 (8–28) |
| b740 | Muscle endurance functions | 67 | 99 | 67 | 99 | 9 (3–18) | 6 | 100 | 6 | 83 | 33 (4–78) | 52 | 94 | 52 | 88 | 10 (3–21) |
| b755 | Involuntary movement reaction functions | 67 | 73 | 67 | 60 | 27 (17–39) | | | | | | 48 | 21 | 52 | 12 | 17 (7–30) |
| b760 | Control of voluntary movement functions | 67 | 84 | 67 | 67 | 21 (12–33) | 37 | 19 | 36 | 8 | 14 (5–29) | 52 | 40 | 52 | 23 | 25 (14–39) |
| b770 | Gait pattern functions | 67 | 97 | 67 | 93 | 28 (18–41) | | | | | | 50 | 92 | 51 | 82 | 24 (13–38) |
| b780 | Sensations related to muscles and movement functions | | | | | | 36 | 44 | 35 | 20 | 29 (15–46) | 51 | 69 | 52 | 58 | 12 (4–24) |
| b810 | Protective functions of the skin | 66 | 52 | 67 | 34 | 24 (15–36) | 37 | 41 | 37 | 30 | 14 (5–29) | 52 | 77 | 52 | 48 | 31 (19–45) |
| b820 | Repair functions of the skin | | | | | | 37 | 30 | 37 | 16 | 16 (6–32) | | | | | |
| 1Number of valid answers. 2Proportion of impairments (“slight/moderate/severe” or “complete”) in the category. 3Proportion of patients experiencing change (improvement or worsening) in the category. Numbers in parentheses represent upper and lower 95% confidence interval limits (CI). |
| Table III. International Classification of Functioning, Disability and Health (ICF) categories of the component Body Structures – percentage of participants with impairment at admission/discharge and the extent of change over time |
| ICF | ICF Code Description | Neurological conditions n = 67 | Cardiopulmonary conditions n = 37 | Musculoskeletal conditions n = 61 |
| Admission | Discharge | Change | Admission | Discharge | Change | Admission | Discharge | Change |
| na | %b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c |
| s110 | Structure of brain | 64 | 53 | 67 | 51 | 2 (0–8) | | | | | | | | | | |
| s120 | Spinal cord and related structures | 66 | 29 | 67 | 22 | 6 (2–15) | | | | | | | | | | |
| s130 | Structures of meninges | 65 | 11 | 67 | 9 | 6 (2–15) | | | | | | | | | | |
| s410 | Structure of cardiovascular system | 65 | 58 | 67 | 60 | 11 (4–21) | 37 | 95 | 37 | 92 | 8 (2–22) | | | | | |
| s430 | Structure of respiratory system | 65 | 28 | 67 | 24 | 12 (23) | 37 | 41 | 36 | 31 | 11 (3–26) | | | | | |
| s530 | Structure of stomach | 65 | 5 | 67 | 12 | 5 (1–13) | | | | | | | | | | |
| s710 | Structure of head and neck region | 67 | 22 | 67 | 16 | 6 (2–15) | | | | | | 61 | 11 | 61 | 8 | 3 (0–11) |
| s720 | Structure of shoulder region | 67 | 21 | 67 | 16 | 16 (8–27) | | | | | | 60 | 12 | 60 | 10 | 2 (0–9) |
| s730 | Structure of upper extremity | 67 | 31 | 67 | 28 | 9 (3–18) | | | | | | 61 | 21 | 61 | 18 | 3 (0–11) |
| s740 | Structure of pelvic region | | | | | | | | | | | 60 | 38 | 60 | 35 | 5 (1–14) |
| s750 | Structure of lower extremity | 67 | 42 | 67 | 37 | 7 (2–17) | | | | | | 61 | 74 | 60 | 68 | 8 (3–18) |
| s760 | Structure of trunk | | | | | | 37 | 24 | 37 | 14 | 11 (3–25) | 60 | 45 | 61 | 36 | 12 (5–23) |
| s810 | Structure of areas of skin | 67 | 52 | 67 | 37 | 18 (10–29) | 37 | 38 | 37 | 30 | 8 (2–22) | 61 | 69 | 61 | 46 | 23 (13–35) |
| aNumber of valid answers. bProportion of impairments (“slight/moderate/severe” or “complete”) in the category. cProportion of patients experiencing change (improvement or worsening) in the category. Numbers in parentheses represent upper and lower 95% confidence interval (CI) limits. |
| Table IV. International Classification of Functioning, Disability and Health (ICF) categories of the component Activities and Participation – percentage of participants with restrictions at admission/discharge and the extent of change over time |
| ICF | ICF Code Description | Neurological conditions n = 67 | Cardiopulmonary conditions n = 37 | Musculoskeletal conditions n = 61 |
| Admission | Discharge | Change | Admission | Discharge | Change | Admission | Discharge | Change |
| na | %b | na | %b | % (CI)c | na | %%b | na | %b | % (CI)c | na | %b | na | %b | % (CI)c |
| d110 | Watching | 66 | 39 | 67 | 33 | 8 (3–17) | | | | | | | | | | |
| d115 | Listening | 66 | 32 | 67 | 22 | 11 (4–21) | | | | | | | | | | |
| d120 | Other purposeful sensing | 64 | 52 | 66 | 36 | 18 (10–30) | | | | | | | | | | |
| d130 | Copying | 64 | 48 | 67 | 39 | 14 (7–25) | | | | | | | | | | |
| d135 | Rehearsing | 66 | 52 | 67 | 43 | 20 (11–31) | | | | | | | | | | |
| d155 | Acquiring skills | 67 | 61 | 67 | 46 | 15 (7–26) | 35 | 20 | 36 | 17 | 3 (0–15) | 50 | 30 | 53 | 30 | 14 (6–27) |
| d160 | Focusing attention | 66 | 53 | 67 | 48 | 12 (5–22) | | | | | | | | | | |
| d166 | Reading | 59 | 49 | 64 | 39 | 17 (8–29) | | | | | | | | | | |
| d170 | Writing | 61 | 70 | 65 | 55 | 30 (19–43) | | | | | | | | | | |
| d175 | Solving problems | 65 | 65 | 66 | 55 | 11 (5–21) | | | | | | | | | | |
| d177 | Making decisions | 64 | 53 | 67 | 48 | 11 (5–21) | 37 | 19 | 36 | 14 | 8 (2–22) | 50 | 20 | 52 | 12 | 8 (2–19) |
| d230 | Carrying out daily routine | | | | | | 37 | 76 | 36 | 47 | 42 (26–59) | 50 | 64 | 52 | 42 | 34 (21–49) |
| d240 | Handling stress and other psychological demands | | | | | | 35 | 46 | 36 | 33 | 24 (11–41) | 56 | 54 | 61 | 43 | 18 (9–30) |
| d310 | Communicating with – receiving – spoken messages | 66 | 38 | 67 | 31 | 12 (5–22) | | | | | | 52 | 2 | 52 | 2 | 4 (0–13) |
| d315 | Communicating with – receiving – nonverbal messages | 65 | 40 | 67 | 36 | 9 (3–19) | | | | | | | | | | |
| d330 | Speaking | 66 | 50 | 67 | 37 | 21 (12–33) | | | | | | | | | | |
| d335 | Producing nonverbal messages | 66 | 47 | 67 | 36 | 15 (8–26) | | | | | | | | | | |
| d350 | Conversation | 66 | 50 | 67 | 37 | 15 (8–26) | | | | | | | | | | |
| d360 | Using communication devices and techniques | 64 | 53 | 66 | 39 | 16 (8–27) | | | | | | | | | | |
| d410 | Changing basic body position | 67 | 93 | 67 | 60 | 46 (34–59) | 37 | 62 | 37 | 38 | 35 (20–53) | 61 | 80 | 61 | 62 | 28 (17–41) |
| d415 | Maintaining a body position | 67 | 85 | 67 | 66 | 31 (21–44) | 37 | 32 | 37 | 11 | 22 (10–38) | 61 | 59 | 61 | 36 | 26 (16–39) |
| d420 | Transferring oneself | 67 | 90 | 67 | 61 | 40 (28–53) | 37 | 43 | 37 | 19 | 30 (16–47) | 61 | 74 | 61 | 43 | 34 (23–48) |
| d430 | Lifting and carrying objects | 67 | 99 | 67 | 90 | 31 (21–44) | 6 | 100 | 6 | 100 | 67 (22–96) | 52 | 100 | 52 | 90 | 33 (20–47) |
| d440 | Fine hand use (picking up, grasping) | 67 | 88 | 67 | 70 | 24 (14–36) | 37 | 27 | 36 | 22 | 11 (3–26) | 52 | 23 | 52 | 17 | 8 (2–19) |
| d445 | Hand and arm use | 67 | 90 | 67 | 75 | 19 (11–31) | 37 | 32 | 37 | 22 | 19 (8–35) | 61 | 30 | 61 | 25 | 10 (4–20) |
| d450 | Walking | 67 | 97 | 67 | 91 | 39 (27–51) | 37 | 76 | 37 | 49 | 46 (29–63) | 61 | 92 | 61 | 84 | 36 (24–49) |
| d460 | Moving around in different locations | 66 | 98 | 67 | 94 | 32 (21–44) | 37 | 76 | 36 | 53 | 47 (30–65) | 52 | 92 | 52 | 87 | 29 (17–43) |
| d465 | Moving around using equipment | 67 | 96 | 66 | 76 | 48 (36–61) | 35 | 69 | 35 | 29 | 49 (31–66) | 52 | 83 | 51 | 61 | 35 (22–50) |
| d510 | Washing oneself | 67 | 96 | 67 | 72 | 42 (30–54) | 37 | 70 | 37 | 49 | 30 (16–47) | 60 | 87 | 61 | 57 | 33 (22–47) |
| d520 | Caring for body parts | 67 | 96 | 67 | 75 | 40 (28–53) | 37 | 73 | 37 | 51 | 27 (14–44) | 60 | 85 | 61 | 59 | 30 (19–43) |
| d530 | Toileting | 67 | 90 | 67 | 64 | 48 (35–60) | 37 | 65 | 37 | 27 | 43 (27–61) | 60 | 78 | 61 | 38 | 43 (31–57) |
| d540 | Dressing | 67 | 93 | 67 | 72 | 46 (34–59) | 37 | 68 | 37 | 46 | 38 (22–55) | 51 | 82 | 52 | 46 | 41 (28–56) |
| d550 | Eating | 66 | 76 | 67 | 52 | 33 (22–46) | 37 | 41 | 37 | 8 | 32 (18–50) | 61 | 26 | 61 | 15 | 11 (5–22) |
| d560 | Drinking | 66 | 70 | 67 | 46 | 38 (26–51) | 37 | 32 | 37 | 5 | 27 (14–44) | 52 | 17 | 52 | 8 | 10 (3–21) |
| d570 | Looking after one`s health | | | | | | 34 | 26 | 34 | 18 | 9 (2–25) | 45 | 40 | 52 | 23 | 22 (11–37) |
| d760 | Family relationships | 39 | 44 | 46 | 35 | 20 (8–37) | 31 | 3 | 32 | 0 | 3 (0–18) | 33 | 18 | 45 | 13 | 6 (1–21) |
| d870 | Economic self-sufficiency | | | | | | 3 | 67 | 2 | 100 | 100 (16–100) | | | | | |
| d910 | Community Life | | | | | | 3 | 67 | 3 | 67 | 100 (16–100) | | | | | |
| d930 | Religion and spirituality | 9 | 56 | 10 | 70 | 0 (0–41) | | | | | | 8 | 0 | 9 | 0 | 0 (0–41) |
| d940 | Human rights | | | | | | | | | | | 12 | 0 | 11 | 0 | 0 (0–31) |
| aNumber of valid answers. bProportion of limitations/restrictions (“slight/moderate/severe” or “complete”) in the category. cProportion of patients experiencing change (improvement or worsening) in the category. Numbers in parentheses represent upper and lower 95% confidence interval (CI) limits. |
Of the categories of the components Body Functions and Structures and the Activities and Participation from the comprehensive ICF Core Sets, 86% were impaired or restricted for patients with neurological conditions in at least one-third of the patients, vs 63% from the cardiopulmonary patient group, and 67% from the musculoskeletal patient group.
Functioning and disability in patients with neurological conditions
The frequency of impairments or restrictions in patients with neurological conditions ranged from 5% to 99% (mean 56%) at admission and from 9% to 94% (mean 47%) at discharge. There was one category at admission with prevalence below or equal to 5%: Structure of stomach (s530).
The Body Functions and Body Structures most frequently impaired both at admission and at discharge were Muscle endurance functions (b740) (99% at admission/99% at discharge), Muscle power functions (b730) (97%/97%), Gait pattern functions (b770) (97%/93%), Structure of cardiovascular system (s410) (58%/60%), and Structure of brain (s110) (53%/51%).
The ICF categories from the component Activities and Participation (A&P) most frequently limited both at admission and at discharge were Lifting and carrying objects (d430) (99%/90%), Moving around in different locations (d460) (98%/94%), and Walking (d450) (97%/91%).
The percentage of patients reporting an improvement in functioning at discharge ranged from 0% to 48% for the different ICF categories. The most frequent improvements were observed in A&P categories Toileting (d530) (48%), Moving around using equipment (d465) (47%), and Dressing (d410) (45%). The Body Functions which improved most frequently were Gait pattern functions (b770) (27%), Respiration functions (b440) (24%), Ingestion functions (b510) (24%), and Defecation functions (b760) (24%). The most frequent improvement in Body Structures was found in the Structure of areas of skin (s810) (16%).
The percentage of patients who reported deterioration on the different ICF categories ranged from 0% to 10%. The most frequent decline was observed in Vestibular functions (b235).
Functioning and disability in patients with cardiopulmonary conditions
In patients with cardiopulmonary conditions, information on the following categories were collected in only a minority of patients: Voice functions (b310), Respiratory muscle functions (b445), Urinary excretory functions (b610), Muscle endurance functions (b740), Lifting and carrying objects (d430), Economic self-sufficiency (d870), and Community Life (d910). For the sake of clarity we report the absolute frequencies of these categories in addition to the presented relative frequencies in the text.
The frequency of impairments or restrictions in patients with cardiopulmonary conditions ranged from 3% to 100% (mean 46%) at admission and from 0% to 100% (mean 33%) at discharge. There were two categories with prevalence below or equal 5% at admission: Consciousness functions (b110) with a prevalence of 5% Family relationships (d760) (3%). Categories of the component Body Functions had the highest prevalence of impairment both at admission and at discharge. As expected, impairments in Functions of the cardiovascular system (b410-b429), Functions of the respiratory system (b440-b449) and Additional functions and sensations of the cardiovascular and respiratory systems (b450-b499) were highly frequent in this patient group. Most frequently impaired at admission were Muscle endurance functions (b740, n = 6) (100%), Exercise tolerance functions (b455) (92%), Respiratory muscles functions (b445) (83%, n = 5), Heart functions (b410) (81%). The most frequently impaired at discharge were Exercise tolerance functions (b455) (86%), Muscle endurance functions (b740) (83%, n = 5), Heart functions (b410) (81%).
The Body Structure most frequently impaired both at admission and at discharge was Structure of cardiovascular system (s410) (95% at admission/92% at discharge). The ICF categories from the component A&P most frequently limited at admission were Lifting and carrying objects (d430) (100%, n = 6), Carrying out the daily routine (d230) (76%), Walking (d450) (76%) and Moving around in different locations (d460) (76%), the most frequently limited at discharge were Lifting and carrying objects (d430) (100%, n = 6), Economic self-sufficiency (d870) (100%, n = 2), Moving around in different locations (d460) (53%), Caring for body parts (d520) (51%), and Walking (d450) (49%).
The percentage of patients reporting an improvement in functioning at discharge ranged from 0% to 100% for the different ICF categories. The most frequent improvements were observed in the categories Economic self-sufficiency (d870) (100%, n = 2), Voice functions (b310) (67%, n = 4), Lifting and carrying objects (d430, n = 4) (67%), Urinary excretory functions (b610) (50%, n = 3), Muscle endurance functions (b740) (33%, n = 2), and Respiratory muscle functions (b445) (33%, n = 2),
The percentage of patients reporting a deterioration in functioning at discharge ranged from 0% to 9% for the different ICF categories. The most frequent decline was observed in Sensation of pain (b280) (9%), Sleep functions (b134) (8%) and Heart functions (b410) (8%).
Functioning and disability in patients with musculoskeletal conditions
The frequency of impairments or restrictions in patients with musculoskeletal conditions ranged from 0% to 100% (mean 52%) at admission and from 0% to 92% (mean 40%) at discharge. There were 3 categories with prevalence below 5%: Communicating with receiving spoken messages (d310) with a prevalence of 2%, and Religion and spirituality (d930) (0%) and Human rights (d940) (0%).
The Body Functions most frequently impaired both at admission and at discharge were Muscle power functions (b730) (95% at admission/92% at discharge), Muscle endurance functions (b740) (94%/88%), Mobility of joint functions (b710) (92%/92%) and Gait pattern functions (s810) (92%/82%).
The Body Structures most frequently impaired were Structure of lower extremity (s750) (74%/68%) and Structure of area of the skin (s810) (69%/49%).
The ICF categories from the component A&P most frequently limited both at admission and at discharge were Lifting and carrying objects (d430) (100%/(0%), Walking (d450) (92%/84%), and Moving around in different locations (d460) (92%/87%).
The percentage of patients reporting an improvement in functioning at discharge ranged from 2% to 42% for the different ICF categories. The most frequent improvements were observed in A&P categories Toileting (d530) (42%), Dressing (d540) (41%), and Walking (d450) (36%). The Body Functions which improved most frequently were Protective functions of the skin (b810) (31%), Sensation of pain (b280) (27%), and Sleep functions (b134) (25%). The most frequent improvement in Body Structures was found in the Structure of areas of skin (s810) (23%).
The percentage of patients reporting a deterioration in functioning at discharge ranged from 0% to 8% for the different ICF categories. The most frequent decline was observed in Stability of joint functions (b715) (8%).
Common aspects of functioning and disability in the 3 patient groups
A comparison of the 3 condition groups showed that there were several categories with highly frequent (> 50% of patients) impairment common to all patient groups at admission. These categories were Exercise tolerance (b455) (64–92%) and Muscle power functions (b730) (68–97%) and the A&P categories Changing basic body position (d410) (62–93%), Lifting and carrying objects (d430) (99–100%), Walking and Moving (d450-d469) (69–98%), and some of the Self-care categories (d510-d540) (65–96%).
Impairments in Gait pattern (b770) (92–97%) and Proprioceptive functions (b260) (67–90%) and limitations in Transferring oneself (d420) (74–90%) were highly prevalent in patients with neurological and musculoskeletal conditions at admission.
Contextual factors
Table V gives an overview of the occurrence of Environmental Factors serving as facilitators or barriers separated by conditions.
| Table V. International Classification of Functioning, Disability and Health (ICF) categories of the component Environmental Factors described as either facilitator or barrier at admission |
| ICF | ICF Code Description | Specification | Neurological conditions n = 67 | Cardiopulmonary conditions n = 37 | Musculoskeletal conditions n = 61 |
| na | %b | na | %b | na | %c |
| e110 | Products or substances for personal consumption | Barrier | 66 | 24 | 32 | 3 | 59 | 7 |
| | | Facilitator | 66 | 98 | 32 | 91 | 59 | 95 |
| e115 | Products and technology for personal use in daily living | Barrier | 65 | 25 | 35 | 6 | 56 | 11 |
| | | Facilitator | 65 | 95 | 35 | 83 | 56 | 98 |
| e120 | Products and technology for personal indoor and outdoor mobility and transportation | Barrier | 65 | 34 | 33 | 9 | 57 | 12 |
| | Facilitator | 65 | 94 | 33 | 100 | 57 | 96 |
| e125 | Products and technology for communication | Barrier | 64 | 25 | 34 | 6 | 48 | 6 |
| | | Facilitator | 64 | 83 | 34 | 82 | 48 | 94 |
| e150 | Design, construction and building products and technology of buildings for public use | Barrier | | | 30 | 17 | 54 | 26 |
| | Facilitator | | | 30 | 73 | 54 | 83 |
| e155 | Design, construction and building products and technology of buildings for private use | Barrier | | | 3 | 33 | | |
| | Facilitator | | | 3 | 100 | | |
| e225 | Climate | Barrier | | | | | 33 | 12 |
| | | Facilitator | | | | | 33 | 45 |
| e245 | Time-related changes | Barrier | | | 29 | 34 | | |
| | | Facilitator | | | 29 | 31 | | |
| e250 | Sound | Barrier | | | 32 | 38 | | |
| | | Facilitator | | | 32 | 31 | | |
| e260 | Air quality | Barrier | | | 4 | 0 | | |
| | | Facilitator | | | 4 | 50 | | |
| e310 | Immediate family | Barrier | 47 | 4 | 32 | 3 | 34 | 9 |
| | | Facilitator | 47 | 100 | 32 | 91 | 34 | 91 |
| e315 | Extended family | Barrier | 17 | 12 | 25 | 4 | | |
| | | Facilitator | 17 | 82 | 25 | 72 | | |
| e320 | Friends | Barrier | 18 | 11 | 24 | 4 | 21 | 0 |
| | | Facilitator | 18 | 89 | 24 | 75 | 21 | 100 |
| e340 | Personal care providers and personal assistants | Barrier | | | | | 29 | 0 |
| | | Facilitator | | | | | 29 | 97 |
| e355 | Health professionals | Barrier | 67 | 4 | 34 | 0 | 60 | 2 |
| | | Facilitator | 67 | 100 | 34 | 91 | 60 | 100 |
| e360 | Health related professionals | Barrier | 36 | 8 | 24 | 0 | | |
| | | Facilitator | 36 | 97 | 24 | 83 | | |
| e410 | Individual attitudes of immediate family members | Barrier | 27 | 0 | 30 | 7 | 21 | 10 |
| | | Facilitator | 27 | 100 | 30 | 87 | 21 | 90 |
| e415 | Individual attitudes of extended family members | Barrier | 11 | 0 | 25 | 4 | | |
| | | Facilitator | 11 | 91 | 25 | 68 | | |
| e420 | Individual attitudes of friends | Barrier | 9 | 0 | 23 | 0 | 14 | 7 |
| | | Facilitator | 9 | 100 | 23 | 65 | 14 | 100 |
| e430 | Individual attitudes of people in positions of authority | Barrier | | | | | 11 | 0 |
| | | Facilitator | | | | | 11 | 91 |
| e440 | Individual attitudes of personal care providers and personal assistants | Barrier | | | | | 20 | 0 |
| | Facilitator | | | | | 20 | 95 |
| e450 | Individual attitudes of health professionals | Barrier | 57 | 4 | 33 | 0 | 56 | 2 |
| | | Facilitator | 57 | 98 | 33 | 79 | 56 | 98 |
| e455 | Individual attitudes of other professionals | Barrier | | | 19 | 0 | | |
| | | Facilitator | | | 19 | 68 | | |
| e465 | Social norms, practices and ideologies | Barrier | 18 | 11 | 24 | 8 | | |
| | | Facilitator | 18 | 78 | 24 | 42 | | |
| e550 | Legal services, systems and policies | Barrier | 26 | 4 | | | | |
| | | Facilitator | 26 | 88 | | | | |
| e555 | Associations and organizational services, systems and policies | Barrier | | | 4 | 0 | 21 | 10 |
| | | Facilitator | | | 4 | 50 | 21 | 90 |
| e570 | Social security, services, systems and policies | Barrier | 44 | 5 | 29 | 3 | | |
| | | Facilitator | 44 | 98 | 29 | 66 | | |
| e575 | General social support services, systems and policies | Barrier | | | 5 | 0 | 31 | 10 |
| | | Facilitator | | | 5 | 80 | 31 | 87 |
| e580 | Health services, systems and policies | Barrier | 58 | 5 | 31 | 0 | 55 | 4 |
| | | Facilitator | 58 | 100 | 31 | 74 | 55 | 100 |
| aNumber of patients in which the interviewers found the respective category relevant to describe the patient comprehensively. bProportion of patients in relation to all in which the interviewers found the respective category relevant to describe the patient comprehensively. |
Environmental factors in patients with neurological conditions
The frequency of facilitators in patients with neurological conditions ranged from 78% to 100% (mean 93%). The frequency of barriers in these patients ranged from 0% to 34% (mean 12%). There were no categories identified as facilitators with prevalence below 5%. Eight categories identified as barriers had prevalence below 5%, as listed in Table V.
The Environmental Factors most frequently serving as facilitators in the patients with neurological conditions were Immediate family (e310), Health professionals (e355), Individual attitudes of immediate family members (e410), Individual attitudes of friends (e420), and Health services, systems and policies (e580). All 5 categories were mentioned as being facilitators by all neurological patients questioned.
The Environmental Factors most frequently serving as barriers in these patients were Products and technology for personal indoor and outdoor mobility and transportation (e115) (34%), Products and technology for personal use in daily living (e115) (25%), Products and technology for communication (e125) (25%), and Products or substances for personal consumption (e110) (24%).
Environmental factors in patients with cardiopulmonary conditions
In patients with cardiopulmonary conditions, information on the following categories was collected in only a minority of patients: Design, construction and building products and technology of buildings for private use (e155), Air quality (e260), Associations and organizational services, systems and policies (e555), and General social support services, systems and policies (e575). For the sake of clarity we provide absolute frequencies of these categories in addition to the relative frequencies presented in the text.
The frequency of facilitators reported by patients with cardiopulmonary conditions ranged from 31% to 100% (mean 73%), whereas the frequency of barriers ranged from 0% to 38% (mean 9%). There were no categories experienced as facilitating in less than 5% of the patients. Twelve categories (48%) were a barrier for less than 5% of the cardiopulmonary patients.
The Environmental Factors most frequently serving as facilitators in the patients with cardiopulmonary conditions were Products and technology for personal indoor and outdoor mobility and transportation (e115) (100%), Design, construction and building products and technology of buildings for private use (e155) (100%, n = 3), Products or substances for personal consumption (e110) (91%), Immediate family (e310) (91%), and Health professionals (e355) (91%).
There were 5 (out of 24) Environmental Factors serving as barriers in more than 10% of the patients. These were Sound e250 (38%), Time-related changes (e245) (34%), and Design, construction and building products and technology of buildings for private use (e155) (33%, n = 1), Health services, systems and policies (e580) (31%), and Design, construction and building products and technology of buildings for public use (e150) (17%).
Environmental factors in patients with musculoskeletal conditions
The frequency of facilitators among patients with musculoskeletal conditions ranged from 45% to 100% (mean 92%), whereas the frequency of barriers ranged from 0% to 26% (mean 7%). There were no categories as facilitators with prevalence below 5%. Seven categories as barriers had a prevalence below 5%.
The Environmental Factors most frequently serving as facilitators in the patients with musculoskeletal conditions were Friends (e320), Health professionals (e355), Individual attitudes of friends (e420), and Health services, systems and policies (e580), each of which was cited by all patients with musculoskeletal conditions. The Environmental Factors most frequently serving as barriers in musculoskeletal patients were Design, construction and building products and technology of buildings for public use (e150) (26%), Products and technology for personal indoor and outdoor mobility and transportation (e120) (12%), Climate (e225) (12%), and Products and technology for personal use in daily living (e115) (11%).
Additional ICF categories
Twenty-six aspects of functioning not previously covered by the comprehensive post-acute ICF Core Sets were identified as relevant by the interviewers. Aspects which were mentioned by at least 1% of the participants are presented in Table VI. All of the newly identified aspects could be translated into corresponding ICF categories. Twelve aspects were translated into categories of the component Body Functions, 12 to categories and chapters of the component Body Structures, and 2 to A&P categories.
| Table VI. Additional International Classification of Functioning, Disability and Health (ICF) categories from the interviews |
| ICF | ICF Code Description | All conditions n = 165 n (%) | Neurological conditions n = 67 n (%) | Cardiopulmonary conditions n = 37 n (%) | Musculoskeletal conditions n = 61 n (%) |
| Body Functions |
| b610 | Urinary excretory functions | 6 (3.64) | 0 (0) | – | 6 (9.84) |
| b430 | Haematological system functions | 4 (2.42) | – | – | 4 (6.56) |
| b540 | General metabolic functions | 3 (1.82) | – | 0 (0) | 3 (4.92) |
| b750 | Motor reflex functions | 3 (1.82) | 3 (4.48) | 0 (0) | 0 (0) |
| b820 | Repair functions of the skin | 3 (1.82) | 0 (0) | – | 3 (4.92) |
| b210 | Seeing functions | 2 (1.21) | – | 0 (0) | 2 (3.28) |
| b310 | Voice functions | 2 (1.21) | – | 2 (5.41) | 0 (0) |
| b415 | Blood vessel functions | 2 (1.21) | – | – | 2 (3.28) |
| b515 | Digestive functions | 2 (1.21) | – | 0 (0) | 2 (3.28) |
| Body Structures |
| s540 | Structure of intestine | 19 (11.5) | 17 (25.37) | 0 (0) | 2 (3.28) |
| s610 | Structure of urinary system | 7 (4.24) | 0 (0) | 2 (5.41) | 5 (8.2) |
| s410 | Structure of cardiovascular system | 4 (2.42) | – | – | 4(6.56) |
| s1 | CHAPTER 1 STRUCTURES OF THE NERVOUS SYSTEM | 3 (1.82) | 1 (1.49) | 0 (0) | 2 (3.28) |
| s570 | Structure of gall bladder and ducts | 3 (1.82) | 1 (1.49) | 2 (5.41) | 0 (0) |
| s730 | Structure of upper extremity | 3 (1.82) | – | 3 (8.11) | – |
| s760 | Structure of trunk | 3 (1.82) | 3 (4.48) | – | – |
| s560 | Structure of liver | 2 (1.21) | 0 (0) | 0 (0) | 2 (3.28) |
| s580 | Structure of endocrine glands | 2 (1.21) | 0 (0) | 2 (5.41) | 0 (0) |
| s630 | Structure of reproductive system | 2 (1.21) | 2 (2.99) | 0 (0) | 0 (0) |
| Activities and Participation |
| d650 | Caring for household objects | 2 (1.21) | 0 (0) | 2 (5.41) | (0) |
| –: not relevant, because the category has already been embodied in the corresponding comprehensive ICF Core Set. |
Discussion
The aim of the present study was to examine the relevance and completeness of the comprehensive ICF Core Sets for patients in post-acute rehabilitation facilities. The observed prevalence and change in functioning and disability and related contextual factors mainly confirms the first version of the comprehensive ICF Core Sets.
All conditions
Patients in post-acute rehabilitation facilities mostly have a long history of hospital and intensive care unit (ICU) stays. Accordingly, patients from all 3 indication groups experienced high rates of impaired Exercise tolerance (b455) and Muscle power functions (b730), which reflects both impairments due to the underlying conditions as well as effects of prolonged immobilization (7–8). These deficits explain the frequent occurrence of limitations in self-care issues. Limitations in mobility issues, such as walking and moving around, lying down, sitting, or standing (included in Changing basic body position (d410)) are also frequently-reported consequences of prolonged immobilization, which underscores the need for additional rehabilitation care (6, 9).
Environmental factors related to personal support and relationships, such as family, friends or healthcare workers, were considered most frequently as facilitators, irrespective of the health condition. Indeed, support by family or friends or community services have previously been identified as relevant in the discharge decision of patients with acute musculoskeletal conditions (7).
Neurological conditions
As expected, impairments in cerebral structures, movement functions and mobility were frequent among patients with neurological conditions. It is notable that we observed significant improvement in self-care tasks during the follow-up interval, especially Toileting (d530) and Dressing (d540), and also improvement in functions related to mobility, both unassisted, and through use of assistive devices. This finding is in line with major rehabilitation goals in patients with neurological conditions such as stroke, namely the attainment of independence in self-care and mobility (8). Swallowing is a major issue in the rehabilitation of acquired brain injuries, and predicts functional outcome (10). The improvements we noted in categories related to respiration and ingestion may be attributed to successful swallowing therapy. We also found that improved mobility was associated with improved defecation functions and increased ability to toilet independently.
We identified some aspects as tending to deteriorate during rehabilitation of neurological patients, namely Vestibular functions (b235), which comprise the sensing of balance and position. Balance disorders and dizziness occurs frequently among patients with neurological disorders arising from cerebrovascular disease (11–12). Paradoxically, seeming deterioration in vestibular function might emerge along with improved mobility, which increases the burden on balance and coordination. It is highly possible that environmental factors, such as family and friends or health system’s policy acting, may act as facilitators of or barriers to patients’ functioning (13).
Seeing functions (b210) and Functions of structures adjoining to the eye (b215) showed low prevalence and hardly any change. Nevertheless, it should be discussed whether these categories should remain in the ICF Core Set because of their importance as basic sensory function.
Cardiopulmonary conditions
In patients with cardiopulmonary conditions the highest prevalence of impairments were observed in categories related to cardiovascular structures and functions, such as Heart functions (b410), Exercise tolerance functions (d455), or Respiration functions (b440). These impairments were associated with difficulties with self-care and mobility. We observed significant improvements during the rehabilitation process in functions related to the kidney (Urinary excretory functions (b610), Muscle endurance functions (b740) and Respiratory muscle functions (b445)). Normalization of diuretic functions is among the first signs of re-compensation after heart failure. Furthermore, the improvements in Respiratory muscle function (b445) may be attributed to lesser dyspnoea resulting from improved heart function.
Musculoskeletal conditions
The most frequently encountered musculoskeletal conditions entailing post-acute rehabilitation were fractures of the extremities, hip, or pelvis. Accordingly, the most frequent impairments were observed in categories related to movement, i.e. muscle and joint functions, and Gait pattern functions (b770). Most frequently, improvements were seen in Walking (d450) and Self-care, in agreement with an earlier report (14).
Approximately 25% of the patients in our study reported improvements in perceived pain, whereas 60% still experienced pain at the end of rehabilitation. In general, pain and sleep disturbance is common among patients after an acute injury, even after the acute phase (15–16).
We noted few additional topics not covered by the present version of the comprehensive ICF Core Sets, with the exception of Structure of intestine (s540), which occurred in 25% of the neurological patients. This association is in line with an earlier study, in which conditions such as peptic ulcer disease, gastrointestinal bleeding and Clostridium difficile proliferation were reported as relatively frequent medical complications following stroke (17). Gastrointestinal disorder should probably be considered as a topic for inclusion in the revised ICF Core Set.
Some limitations of our study may limit the generalizability of the results. The sample included only patients from German-speaking countries with comparable healthcare systems where post-acute rehabilitation facilities are well-established. The collection of data elsewhere in Europe, or on other continents, might well have yielded different results. Therefore, additional validation studies with patients from other countries and cultures should be carried out in the next phase of validation of the ICF. Impairments and limitations experienced by our patients may be a direct consequence of the underlying diagnoses encountered in the particular study. We are, however, confident that the current sample of older patients reflected the prototypical spectrum of diagnoses seen in Western Europe. However, this does not obviate the need to test the comprehensive ICF Core Sets as often as possible, and in many different settings. Another limitation pertains to the fact that due to administrative problems not all categories could be applied to all patients. We are aware that this weakens evidence on those categories.
In conclusion, all categories of the comprehensive ICF Core Sets for the post-acute rehabilitation situation were confirmed due to their sensitivity to change. Categories that showed low prevalence or less change should be investigated particularly in further studies with respect to their significance for the patients. These future results should be put up for discussion among researchers and clinicians in the field of post-acute rehabilitation. All in all, we could not identify significant gaps in the established sets.
AcknowledgementS
The authors thank all the study participants for their patience and collaboration, and Dr Paul Cumming for manuscript revisions. We further thank all participating hospitals involved in data collection, Kaiser-Franz-Josef-Hospital, Institute of Physical Medicine and Rehabilitation, Vienna (Austria), SMZ-Sophienspital, Ludwig Boltzmann Institute for Interdisciplinary Rehabilitation in Geriatrics, Vienna (Austria), University Hospital Munich, Department of Physical Medicine and Rehabilitation (Germany), General Hospital Munich Schwabing, Munich (Germany), Clinic and Institute for Physical and Rehabilitative Medicine, Nürnberg Süd Hospital (Germany), Institute for Physical and Rehabilitative Medicine, Ingolstadt Hospital (Germany), Malteser Krankenhaus, Department of Geriatrics, Bonn (Germany), Schön-Klinik Rosenheim (Germany) and Geriatric Rehabilitation Hospital Würzburg (Germany). The project was supported by the German Ministry of Health and Social Security (BMGS) grant no. 124-43164-1/501 and the LMUinnovativ project Münchner Zentrum für Gesundheitswissenschaften, (TP 1).
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