Content » Vol 43, Issue 2

Original report

Validation of the comprehensive ICF Core Sets for patients in early post-acute rehabilitation facilities

Martin Müller, RGN, Dipl. Nurs. Mngt.1,2, Marita Stier-Jarmer, PhD1,2, Michael Quittan, MD3,
Ralf Strobl, Dipl. Stat1,2, Gerold Stucki, MD, MS2,4,5 and Eva Grill, DrPH, PhD1,2

From the 1Institute for Health and Rehabilitation Sciences (IHRS), Munich, Germany, 2ICF Research Branch of WHO Collaborating Centre for the Family of International Classifications in German, Nottwil, Switzerland, 3Kaiser-Franz-Joseph-Spital, Vienna, Austria, 4Swiss Paraplegic Research, Nottwil and 5Seminar of Health Sciences and Health Policy, University of Lucerne, Switzerland

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

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).

References

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