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PHYS THER
Vol. 87, No. 4, April 2007, pp. 368-384
DOI: 10.2522/ptj.20050237
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Research Reports

Validation of the Comprehensive International Classification of Functioning, Disability and Health Core Set for Rheumatoid Arthritis: The Perspective of Physical Therapists

Inge Kirchberger, Andrea Glaessel, Gerold Stucki and Alarcos Cieza

I Kirchberger, PhD, MPH, is Research Scientist, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians University, Munich, Germany
A Glaessel, PT, MSc, is Research Scientist, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the DIMDI, Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians University
G Stucki, MD, MSc, is Research Scientist, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the DIMDI, Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians University, and Professor and Head, Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians University, Marchioninistrasse 15, D-812377 Munich, Germany
A Cieza, PhD, MPH, is Research Scientist and Group Leader, ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the DIMDI, Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians University

Address all correspondence to Dr Stucki at: gerold.stucki{at}med.uni-muenchen.de


Submitted August 1, 2005; Accepted December 22, 2006


   Abstract
 
Background and Purpose: The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Rheumatoid Arthritis (RA) represents the typical spectrum of problems in the functioning of patients with RA. The objective of this study was to validate this ICF Core Set from the perspective of physical therapists.

Methods: Physical therapists were asked about their intervention goals in a 3-round Delphi survey. Intervention goals were compiled, and the physical therapists were asked whether they considered the goal classes to be relevant. The goal classes then were linked to the ICF.

Results: A total of 82 physical therapists in 12 countries named 562 intervention goals. A total of 45 goal classes covering all ICF components were identified. The goal classes addressing muscle tone, balance and coordination, and psychological distress were not represented in the ICF Core Set for RA.

Discussion and Conclusion: The validity of the ICF Core Set for RA was largely supported. However, some categories currently not covered by the ICF Core Set for RA will need to be investigated further.


   Introduction
Top
 Abstract
 Introduction
Method
 Results
 Discussion and Conclusion
 References
 
Rheumatoid arthritis (RA) is associated with impairments in functions and body structures, including pain, joint stiffness, joint swelling, reduced range of motion, loss of muscle strength (force-generating capacity), joint damage, and fatigue.1,2 Such impairments often lead to limitations in physical activities and restrictions in daily activities and societal participation, including paid work.3–8

Physical therapy is used frequently for patients with RA.9,10 Physical therapists commonly use physical modalities for pain management, design and prescribe therapeutic exercises focusing on strengthening and endurance activities and aerobic capacity, apply joint and soft-tissue mobilization, and educate patients about their disease and its management.11–14 Although the scientific evidence for physical therapy interventions generally is limited, recently a number of systematic reviews summarized studies of a considerable number of relevant interventions, such as dynamic exercise therapy,15 thermotherapy,16 balneotherapy,17 transcutaneous electrical nerve stimulation,18 and patient education.19

To optimize interventions aimed at maintaining functioning and minimizing disability, a proper understanding of patients' functioning and health status is needed.20 The International Classification of Functioning, Disability and Health (ICF) and the integrated biopsychosocial model on which it is based provide a useful framework for achieving this understanding.21 According to the integrated biopsychosocial model of functioning and disability, functioning, with its components "body functions and structures" and "activities and participation," is viewed in relation to the health condition under consideration as well as personal and environmental factors (Fig. 1).


Figure 1
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  		Figure 1. Biopsychosocial model of functioning and disability. Reprinted from International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001 with permission of the World Health Organization.

 
Because the described integrated biopsychosocial model guided the development of the ICF, the components of the classification correspond to the components of the model. Within each component, except for "personal factors," there is an exhaustive list of so-called ICF categories, which are the units of the classification. The ICF categories are hierarchically organized in a scheme that can be compared to a stem-branch-leaf scheme and are denoted by unique alphanumeric codes (Fig. 2). The first level of the hierarchy comprises chapters. Categories at higher levels (eg, third or fourth level) are more detailed. A higher-level (more detailed) category shares the attributes of the lower-level categories of which it is a member; that is, the use of a higher-level category implies that the lower-level categories are applicable.


Figure 2
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  		Figure 2. Structure of the International Classification of Functioning, Disability and Health (ICF). The ICF has a stem-branch-leaf structure in which the higher (more specific) level always can be traced back to the lower (less specific) level. The World Health Organization document International Classification of Functioning, Disability and Health: ICF21 provides definitions of the various levels.

 
Both the content and the structure of the ICF indicate its potential value for the rehabilitation professions.22 In contrast to profession-specific guides, such as the Guide to Physical Therapist Practice23 of the American Physical Therapy Association, the common language of the ICF extends across different professions and health care disciplines. Therefore, ICF data can be communicated effectively among the members of rehabilitation teams and across different health care situations, such as acute care, rehabilitation, and community health care situations, in all of which physical therapists are involved.

Also in contrast to the Guide to Physical Therapist Practice,23 the ICF does not delineate tests, measures, and interventions that are used in physical therapist practice. It can, however, be used as a basis from which the selection of tests, measures, and interventions can be standardized. As was shown recently,24 the ICF can be used as a fundamental reference or framework across technical, clinical, and patient-oriented measures and interventions.

Despite its supposed value, the ICF classification as a whole—including more than 1,400 categories—is not feasible for use in clinical practice. To facilitate the implementation of the ICF into clinical practice, ICF Core Sets for a number of health conditions, including RA,25 have been developed by collaboration between the ICF Research Branch of the World Health Organization (WHO) Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information, Institute for Health and Rehabilitation Sciences, Ludwig-Maximilians University, Munich, Germany (http:\\www.ICF-Research-Branch.org), and the WHO.26–28

The Comprehensive ICF Core Set for RA includes a set of 96 categories selected from among the ICF classification as a whole and covering the typical spectrum of problems in functioning in patients with RA.25 It was developed by a formal decision-making and consensus process integrating evidence gathered from preliminary studies by experts consisting of rheumatology health care professionals. Preliminary studies included a Delphi study, a systematic review, and an empiric data collection.28

The ICF Core Set for RA defines the areas that are relevant to functioning in patients with RA and consequently what to measure in patients with RA from a comprehensive and multiprofessional perspective.29 The ICF Core Set for RA, therefore, can be used as a starting point in the examination of patients with RA. A functioning profile can be created on the basis of that examination and subsequently can be used to document intervention goals and as a reference for follow-up.

However, a prerequisite is that the Comprehensive ICF Core Set for RA should include all aspects of functioning and relevant environmental factors that are intervention goals for all of the health care professions involved in the care of patients with RA. Therefore, the objective of this study was to validate the Comprehensive ICF Core Set for RA from the perspective of physical therapists. The specific aims were first to identify the intervention goals that are relevant for physical therapists treating patients with RA and second to examine how these intervention goals are represented by the current version of the Comprehensive ICF Core Set for RA.


   Method
Top
 Abstract
 Introduction
 Method
Results
 Discussion and Conclusion
 References
 
We conducted a 3-round electronic-mail survey of physical therapists using the Delphi technique.30–33 The Delphi technique is applied to gain a consensus from a panel of people with knowledge of the topic being investigated.34 These informed people are commonly referred to as "experts."35 The Delphi technique is a multistage process in which each stage builds on the results of the previous stage and in which a series of rounds are used both to gather and to provide information about a particular topic. The technique is characterized by its anonymity to avoid the dominance of single individuals in a group; iteration, which allows panel members to change their opinions in subsequent rounds; and controlled feedback, which shows the distribution of a group's responses as well as each individual's previous responses.32 Delphi surveys conducted with 2 or 3 rounds are preferred to increase participant compliance and the stability of the responses.36,37

Recruitment of Participants

In the preparatory phase of the study, associations of physical therapists and hand therapists worldwide, as well as the Association of Rheumatology Health Professionals, were identified by an Internet search and contacted. In addition, an Internet search and personal recommendations were used to identify individual physical therapists experienced in the treatment of patients with RA. A register of German rheumatology hospitals was used to contact German physical therapists. The sample was selected by use of a purposive sampling approach. Purposive sampling is based on the assumption that a researcher's knowledge about the population can be used to select the cases to be included in the sample.38

To ensure that the participants in the study were knowledgeable concerning the treatment of patients with RA, the initial letter specified that participants should be "physical therapists experienced in the treatment of RA." The first contact included an invitation to cooperate and a detailed description of the project targets, the Delphi process, and the timeline. Only therapists who agreed to participate were included in the sample and received the questionnaire for the first Delphi round.

Delphi Process

The Delphi process and verbatim questions of the electronic-mail survey are shown in Figure 3. The physical therapist experts had 3 weeks to mail their responses for each round. Reminders were sent 1 week and 2 days before the deadline.


Figure 3
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  		Figure 3. Description of the Delphi exercise. RA=rheumatoid arthritis.

 
In round 1 of the Delphi procedure, an informational letter and an Excel* file containing an open-ended questionnaire were sent to all physical therapist experts. The informational letter included instructions for the physical therapist experts. In the questionnaire, the physical therapist experts were requested to list all intervention goals and the corresponding interventions that they applied to reach those goals for patients with RA. Additionally, the physical therapist experts were requested to complete questions on demographic characteristics and professional experience.

The responses from the first round were collected and compiled by the research team. For the intervention goals, the steps were as follows: compiling of goals with identical or similar meanings, definition of an umbrella term (goal class) applicable to all of the intervention goals compiled in the previous step, and calculation of the number of participants who considered the goal class to be relevant when treating patients with RA.

The first and second steps were performed by a physical therapist (AG) and a psychologist (IK). Both people were experienced in qualitative research methods in general and especially in the Delphi technique. In cases of disagreement, 2 other experienced physical therapists discussed the problem, and a joint decision was made. The third step was performed by the project leader (IK).

Goal classes were predominantly labeled "influence." This broad term should cover the main options of rehabilitation, namely, prevention, restoration, and maintenance.39

According to the named goals at different levels of specificity, classes with different levels of abstraction were created. For example, the named intervention goal "improve/keep muscle function" was assigned to the class "influence muscle function," whereas the named goal "improve/maintain strength" was assigned to the more specific class "influence muscle strength," although muscle strength may be regarded as a subcategory of muscle function. Goals that were too nonspecific to be classified were assigned to a "nonspecified" category.

In the second Delphi round, the physical therapist experts who responded in round 1 received a list of the goal classes, including the proportion and number of participants who considered the goal classes to be relevant for the treatment of patients with RA. Goal classes were ordered by chance. The physical therapist experts were asked whether they considered the goal classes to be relevant when they treated patients with RA. Again, the number of physical therapist experts considering the listed goal classes to be relevant was calculated. In the third Delphi round, the physical therapist experts were requested to answer the same questions but to take into account the answers of the group as well as their previous answers.

Linking

An ICF category is coded by the component letter and a suffix of 1 to 5 digits. The letters "b," "s," "d," and "e" refer to the components "body functions" (b), "body structures" (s), "activities and participation" (d), and "environmental factors" (e) (Fig. 2). The letter is followed by 1 digit indicating the chapter, the code for the second level (2 digits), and the codes for the third and fourth levels (1 digit each). A higher-level (more detailed) category shares the lower-level categories of which it is a member; that is, the use of a higher-level category implies that the lower-level categories are applicable, but not the other way around.

Each goal class was linked to the most precise ICF category. The linking was performed separately by 2 trained health care professionals using 10 linking rules established in an earlier study.40 These health care professionals were not involved in the previous process of compiling of answers and definition of goal classes. If a goal class contained more than one concept, then several ICF categories could be linked. Consensus among health care professionals was used to decide which ICF category should be linked to each goal. In cases of disagreement between the 2 health care professionals, the suggested categories were discussed by a team consisting of 2 physical therapists and 2 psychologists. On the basis of this discussion, a joint decision was made.

Statistical Methods

Statistical analysis was performed with SAS for Windows, version 8.{dagger} Descriptive statistics were used to characterize the sample and frequencies of answers. To analyze group differences, a chi-square test or a Fisher exact test was applied for nominal variables, and a Mann-Whitney U test was applied for ordinal variables. The level of significance was set to .05. Kappa statistics with bootstrapped confidence intervals were used to describe the agreement between the 2 health care professionals who performed the linking.41,42


   Results
Top
 Abstract
 Introduction
 Method
 Results
Discussion and Conclusion
 References
 
Recruitment and Participants

A total of 75 associations of physical therapists and hand therapists were contacted worldwide. Ten associations named 30 people, and 22 people participated in the first round of the Delphi process. Of the Association of Rheumatology Health Professionals, 36 members were invited to participate; 6 agreed to participate, and 4 participated in the first round of the study. By an Internet search, 2 additional physical therapist experts who participated in the study were contacted. On the basis of personal recommendations of other participants ("snowball system"), 25 physical therapist experts were contacted; 20 agreed to participate, and 15 finally participated in the first round of the Delphi process. A total of 22 heads of physical therapy departments at German rheumatology hospitals were contacted; 4 of them named 39 physical therapist experts who participated in the first round of the Delphi process.

The Delphi procedure was conducted between April 2004 and June 2004. A total of 86 of 103 physical therapist experts (83.5%) who agreed to participate in the study completed the first-round questionnaire. Four questionnaires could not be analyzed because the participants returned them after the deadline (n=1), did not use English or German (n=2), or answered the questions not from a clinical perspective but from a research perspective (n=1).

The demographic and professional characteristics of the remaining 82 physical therapist experts are shown in Table 1. More than one half of the physical therapist experts (54.9%) were German. Significant differences were found between the German physical therapist experts and the other physical therapist experts. German physical therapist experts were significantly younger (median=39.0 and 46.0 years of age, respectively; P=.017), the duration of their professional experience was significantly shorter (median=11.0 and 19.0 years of experience, respectively; P=.002), and the duration of their experience with patients with RA also was significantly shorter (median=9.0 and 13.5 years of experience; P=.037). No significant changes in demographic characteristics because of attrition of physical therapist experts among the 3 Delphi rounds could be found.


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  		Table 1. Attrition of Participants Among the Delphi Rounds, Demographics, and Professional Experience of the Round 1 Participants

 
Delphi Process

In the first Delphi round, 562 intervention goals were named, and 45 goal classes were identified. Nine of the named intervention goals, including "prevention," "reduce disability," and "mobilization," were assigned to the "nonspecified" category.

A total of 77 of 82 physical therapist experts (93.9%) returned the second-round questionnaire. The third-round questionnaire was completed by 62 of 77 physical therapist experts (80.5%). The results, including the percentage of participants considering each of the goal classes to be relevant, are shown in Tables 2, 3, 4, 5, and 6.


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  		Table 2. International Classification of Functioning, Disability and Health (ICF) Component "Body Functions": ICF Categories Included in the ICF Comprehensive Core Set (Boldface Letters) and ICF Categories Linked to Goal Classes but Not Included in the ICF Comprehensive Core Set (Lightface Letters)a

 

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  		Table 3. International Classification of Functioning, Disability and Health (ICF) Component "Body Structures": ICF Categories Included in the ICF Comprehensive Core Set (Boldface Letters) and ICF Categories Linked to Goal Classes but Not Included in the ICF Comprehensive Core Set (Lightface Letters)a

 

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  		Table 4. International Classification of Functioning, Disability and Health (ICF) Component "Activities and Participation": ICF Categories Included in the ICF Comprehensive Core Set (Boldface Letters) and ICF Categories Linked to Goal Classes but Not Included in the ICF Comprehensive Core Set (Lightface Letters)a

 

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  		Table 5. International Classification of Functioning, Disability and Health (ICF) Component "Environmental Factors": ICF Categories Included in the ICF Comprehensive Core Set (Boldface Letters) and ICF Categories Linked to Goal Classes but Not Included in the ICF Comprehensive Core Set (Lightface Letters)a

 

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  		Table 6. Goal Classes That Were Linked to the International Classification of Functioning, Disability and Health (ICF) Component "Personal Factors" or Could Not Be Linked to a Specific ICF Category Because More Specific Information Would Have Been Required ("Not Definable") or the Concept Was Not Covered by the ICF ("Not Covered")

 
Analysis revealed significant differences between the ratings of the German physical therapist experts and those of the physical therapist experts from other countries. A total of 12 of 45 goal classes were considered to be relevant by a significantly higher proportion of German physical therapist experts in the third Delphi round. Within the non-German sample, physical therapist experts who considered a goal class to be relevant did not differ significantly from those who did not with regard to age, professional experience, or self-rated expertise in the treatment of patients with RA. Concerning experience in the treatment of patients with RA, a significantly lower proportion of physical therapist experts (57.1%) with more experience (greater than or equal to the median) in the treatment of patients with RA than of physical therapist experts (100%) with less experience (less than the median) considered "develop common treatment goals" to be relevant.

Linking of the Goal Classes to the ICF

All components of the ICF were represented in the 45 goal classes (Tabs. 2, 3, 4, 5, and 6). Two third-level categories, 17 second-level categories, and 1 chapter of the component "body functions" were linked. The component "body structures" was represented by 4 third-level categories. One third-level category, 4 second-level categories, and 1 chapter of the component "activities and participation" and 2 second-level categories and 2 chapters of the component "environmental factors" were linked. Six goal classes were linked to the not-yet-developed ICF component "personal factors." Two goal classes were found not to be covered by the ICF, and 4 goal classes were not defined sufficiently to be linked. The kappa statistic for the linking was .70, and the 95% bootstrapped confidence interval was .56 to .84.

Representation of the Physical Therapists' Intervention Goals in the Comprehensive ICF Core Set for RA

The physical therapists' intervention goals addressed 10 of the 15 second-level categories (66.7%) of the component "body functions" in the Comprehensive ICF Core Set. Nine goal classes were linked to ICF categories of the component "body functions" that are represented in the Comprehensive ICF Core Set for RA at the same level of the classification (Tab. 2). The goal "influence energy level" was linked to the third-level category "b1300: energy level," which was represented in the Comprehensive ICF Core Set by the second-level category "b130: energy and drive functions."

On the basis of the stem-branch-leaf structure of the ICF, the higher-level (more specific) ICF categories always can be traced back to the lower-level (less specific) ICF categories. Therefore, a number of intervention goals were linked to higher-level ICF categories that were represented in the Comprehensive ICF Core Set for RA by lower-level categories.

"Influence body functions" was linked to the ICF at the component level, and the goal class "influence general body mobility" was linked to chapter "b7: neuromusculoskeletal and movement-related functions." This chapter was represented by 6 second-level categories in the Comprehensive ICF Core Set for RA; 5 of them were addressed by the goal classes "influence joint ROM," "influence joint stability," "influence muscle strength," "influence muscle endurance," and "influence gait." However, 4 goal classes that were linked to categories belonging to chapter b7 were not represented in the Comprehensive ICF Core Set for RA, namely, "influence muscle function," "influence muscle tone," "influence muscular balance," and "influence balance and coordination." Furthermore, the goal classes "influence circulation," "influence lymphatic circulation," and "influence metabolism" were not covered by ICF categories included in the Comprehensive ICF Core Set for RA.

Six goal classes were linked to 4 different third-level categories of the component "body structures" (Tab. 3). They were represented in the Comprehensive ICF Core Set for RA by the second-level category "s770: additional musculoskeletal structures related to movement."

The goal class "influence activities of daily living" addressed a broad range of second-level categories of the ICF component "activities and participation" and therefore was linked at the component level (Tab. 4). The goal classes "influence mobility in environment" and "influence general body mobility" were linked to chapter "d4: mobility." The goal class "influence walking" could be linked specifically to category "d450: walking." The goal class "prevention of falls" was linked to the third-level category "d5702: maintaining one's health," which was represented in the Comprehensive ICF Core Set for RA by the corresponding second-level category "d570: looking after one's health." The goal class "influence reintegration into work" was represented in the Comprehensive ICF Core Set for RA by category "d850: remunerative employment." Only category "d240: handling stress and other psychological demands," which was linked to the goal class "influence psychological distress," was not included in the Comprehensive ICF Core Set for RA.

The goal classes "influence the use of aids" and "involve significant others" were linked to 2 of the 5 chapters of the ICF component "environmental factors," namely, "e1: products and technology" and "e3: support and relationships" (Tab. 5). The goal class "influence work and house ergonomics" was linked to the second-level categories "e135: products and technology for employment" and "e155: design, construction, and building products and technology of buildings for private use," which were included in the Comprehensive ICF Core Set for RA.

Six of the goal classes were linked to the not-yet-developed ICF component "personal factors" (Tab. 6). Most of them addressed attitudes supporting a patient's independence in managing his or her disease, such as self-responsibility, self-management, self-efficacy, and independence or autonomy. "Influence disease and behavior knowledge" and "influence coping with disease" also were considered to constitute "personal factors" according to the ICF language.

Four goal classes, namely, "influence quality of life," "develop common treatment goals," "influence nervous system," and "guiding," were too nonspecific for making a decision about which ICF category to which they should be linked (Tab. 6). The goal classes "influence muscular balance" and "influence compensatory movement" were found not to be covered by the ICF (Tab. 6).


   Discussion and Conclusion
Top
 Abstract
 Introduction
 Method
 Results
 Discussion and Conclusion
References
 
The results of this study support the validity of the Comprehensive ICF Core Set for RA from the perspective of physical therapists and emphasize the broad spectrum of areas in functioning addressed by physical therapists in their interventions. Many of the physical therapists' intervention goals were included in the Comprehensive ICF Core Set. However, some issues that are not yet covered by the Comprehensive ICF Core Set or even not by the ICF classification as a whole emerged.

Most of the intervention goals addressed the functioning of muscles and joints. Besides the umbrella term "influence muscle function," several specific goals concerning muscle strength, endurance, tone, and balance were named. However, "influence muscle tone" was not represented in the Comprehensive ICF Core Set, although it was regarded as a relevant intervention goal by 97.2% of the German physical therapist experts. On the other hand, only 64.0% of the non-German physical therapist experts considered this goal to be relevant for their work with patients with RA.

Several intervention techniques generally used by physical therapists for the treatment of patients with RA are considered to positively influence muscle tone.12 The application of heat,11,13 hydrotherapy,12,13 and massage12,43 may relax muscles and, as a consequence, contribute to pain relief. According to Clark,14 these techniques should be used to prepare patients for exercise and should not be viewed as primary interventions. Therefore, several physical therapist experts may have considered the reduction of muscular tension to be a secondary goal for achieving other goals at a higher level of importance. Furthermore, the significant difference between the German and non-German physical therapist experts may be explained by country-specific differences concerning the practice of massage techniques that often are applied to reduce muscle tension.10,43

Three additional goal classes that were not covered by the Comprehensive ICF Core Set were found. "Influence circulation," "influence lymphatic circulation," and "influence metabolism" were regarded as relevant by 31% to 36% of the non-German physical therapist experts and by 72% to 89% of the German physical therapist experts. One aspect of the goal class "influence circulation," the cardiovascular circulation, also was part of the goal class "influence cardiovascular and general fitness." Category "b455: exercise tolerance functions" in the Comprehensive ICF Core Set covered this important target in the rehabilitation of patients with RA.12,13 Obviously, most of the physical therapy interventions have an impact on circulation, lymphatic circulation, and metabolism. Dynamic exercise has been shown to increase synovial blood flow in patients with RA, and motion may improve joint metabolism.13 Massage therapy increases blood flow in muscles and lymphatic flow, and therapeutic cold reduces the local metabolic rate.12,13 However, these effects cannot be regarded clearly as primary intervention goals, and this fact may be reflected by the voting of the non-German physical therapist experts.

Reduced muscle function in patients with RA also may present as a loss of balance and coordination.44 Physical therapists are requested to consider both aspects in their interventions.12,13 However, the ICF categories "b755: involuntary movement reaction functions," addressing balance, and "b760: control of voluntary movement functions," addressing coordination, were not included in the Comprehensive ICF Core Set for RA. At the consensus conference that led to the definitions in the Comprehensive ICF Core Set for RA, the question as to whether "b760: control of voluntary movement functions" should be included in the Comprehensive ICF Core Set to represent coordination was discussed extensively by the experts.24 Ultimately, the category was not included because the definition is related more to neurological aspects not primarily relevant for patients with RA and because other categories, including "b770: gait pattern functions," may represent this issue. The reasons for problems with balance and coordination in RA are indeed of a different nature. An appropriate category reflecting this issue could be included in the ICF.

Preventing falls was regarded as a relevant intervention goal by 81% of the non-German physical therapist experts and by 58% of the German physical therapist experts. Indeed, patients with RA are found to be more likely to fall than healthy control subjects,45 probably because of stiff and painful joints, muscle weakness,46 and alterations in gait.47,48 "Prevention of falls" was linked to the ICF category "d5702: maintaining one's health," and the corresponding second-level category "d570: looking after one's health" was included in the Comprehensive ICF Core Set. However, one could argue that falls are not covered precisely by these categories. Because falls are events that often occur in patients with various health conditions and may be relevant for the rehabilitation of patients, it may be useful to develop an ICF category that addresses falls more specifically.

Physical therapists use postural training to help patients reduce stress on joints or soft tissues during regular movement, work, and recreational activities and to prevent or reduce postural deformities.11,14 The goal class "influence posture" was linked to the ICF category "d415: maintaining a body position." However, the description of its content, "staying in the same body position as required, such as remaining seated or remaining standing for work or school," indicates clearly that it does not cover the meaning of posture comprehensively. It covers the aspect of postural instability in terms of balance during standing or sitting and focuses on the static aspect of posture. This aspect seems to be less relevant for most patients with RA than the dynamic aspect of posture. Therefore, physical therapists' interventions may not be covered exactly by this ICF category.

The goal class "influence psychological distress" was linked to 2 different categories; "b152: emotional functions" was part of the ICF component "body functions," and "d240: handling stress and other psychological demands" was assigned to the ICF component "activities and participation." However, "d240: handling stress and other psychological demands" was not included in the Comprehensive ICF Core Set. The inclusion of this category was discussed by the expert panel at the consensus conference that led to the development of the Comprehensive ICF Core Set for RA. Taking into account the large number of categories included in the Comprehensive ICF Core Set for RA, the experts decided that the psychosocial factors influencing RA disability will be represented sufficiently by the category "b152: emotional functions."25

Six goal classes were linked to the not-yet-developed ICF component "personal factors." A patient's self-management, self-responsibility, self-efficacy, independence or autonomy, disease and behavior knowledge, and abilities to cope with the disease commonly are influenced by physical therapists using patient education.13 Various studies and systematic reviews have supported the positive effects of patient education on self-management,49 self-efficacy,50–52 and coping with disease.53 These results have shown clearly that physical therapists do not work exclusively on the level of body structures and body functions or activities but have an influence on personal factors as well. The findings stress the need to develop the ICF component "personal factors." Otherwise, a description of relevant aspects that influence a patient's functioning and health will not be comprehensive and complete.

Two goal classes that were not included in the ICF classification were found. Reduced strength and reduced flexibility of specific muscle groups frequently result in general muscular imbalance in patients with RA. The restoration of muscle balance with exercise therapy is an important task of physical therapists.13 However, there is no specific ICF category covering muscle balance or imbalance because this issue can be described more precisely with categories concerning muscle power functions, muscle tone functions, and muscle endurance functions.

"Influence compensatory movement" addresses physical therapists' efforts to compensate for impairments in motion by teaching patients alternative ways to perform specific movements. The use of compensatory movements may result in improved abilities to perform activities and to participate in daily life; therefore, this goal class could be regarded as being covered by the ICF component "activities and participation."

The Delphi technique proved to be an appropriate method for our study objective. In contrast to mean attrition rates of 50% or higher from round to round reported in the literature, response rates of 80.5% to 93.9% between rounds were achieved in our study.54,55 Because attrition cannot be avoided completely, it is regarded as essential that a range of expert opinions be adequately represented in successive rounds.56 This requirement was fulfilled in the sample studied here.

However, there are some limitations regarding the external validity and reliability of this study. Although we were successful in recruiting physical therapists from 12 countries, the sample was not representative of all physical therapists who are experienced in the treatment of patients with RA worldwide. Because no database including the target population is available, random sampling was not possible. The impossibility of random sampling characterizes qualitative research methods in general and the Delphi method in particular.56

The German physical therapist experts had significantly different opinions concerning the relevance of many intervention goals. Because the compiled answers used in the second and third Delphi rounds represented the total sample, we cannot exclude the possibility that this study design influenced the responses of the physical therapist experts. The differences found may be attributable to country-specific differences in treatment guidelines or variations in the practice of physical therapy interventions9 as well as to an overall tendency among Germans to agree with the items in the questionnaires.

To avoid the overrepresentation of German physical therapist experts and the possible influence of this imbalance on the results, a random selection of about 5 participants from the pool of 45 German physical therapists could have been performed. Further validation studies including physical therapists from countries not sufficiently represented in this study and with a balanced distribution of participants by country should be conducted in the future.

Readers of this journal working with patients with RA in countries that were not represented in this Delphi study are requested to comment on the results with regard to their clinical experience. This procedure could help us to obtain additional insights regarding the validity of the results presented in this article.

The compiling of the named intervention goals in the first Delphi round was performed by 2 health care professionals, who had to agree on each assignment of a named goal to a goal class. However, it remains unclear whether other health care professionals would have decided differently. In contrast, the agreement of the 2 people who linked the goal classes to ICF categories was quantified with kappa statistics and proved to be satisfactory.

The development of the ICF is recognized as an important contribution to the field of physical therapy and rehabilitation. Its provision of a universal and standardized language and framework regarding disability that extends beyond mortality and disease is highly valued.57 However, only if physical therapists start to implement the ICF in clinical practice will it be possible to prove its potentials and limitations for the practice of physical therapy. The ICF Core Sets constitute a contribution within a multidisciplinary setting.

In addition, the potential benefits of applying the Comprehensive ICF Core Set for RA in physical therapy may be concluded from this study. It was shown that the physical therapists' intervention goals were not limited to body functions. This finding emphasizes the need to consider all ICF components in assessments and in outcome evaluations of interventions applied by physical therapists. The ICF Core Sets and professionspecific classification systems, such as the Guide to Physical Therapist Practice,23 may complement each other in a very useful manner.

The ICF Core Sets could be used by physical therapists to document their intervention goals in a standardized way, facilitating both interprofessional and international communications. When also used by other health care professionals in a multidisciplinary team, the ICF Core Sets emphasize the core competence of different health care professions. The ICF Core Sets can be viewed as the common platform from which different professionals start their assessments and interventions and to which they return when discussing the treatment of patients and common intervention goals. However, the ICF Core Sets do not provide guidance to physical therapists or other professionals on how to assess the different ICF categories or how to intervene. This specific professional information is provided by classification schemes such as the Guide to Physical Therapist Practice, which lists the appropriate tools for measuring ICF categories, such as joint mobility, and the interventions for improving the mobility of joints.23

It is important to emphasize that the Comprehensive ICF Core Set for RA contains the intervention goals not only of physical therapists but also of all health care professionals involved in the treatment of patients with RA. These tools are designed to be used within a multidisciplinary setting. Studies similar to the one presented in this article are currently being performed with other health care professionals involved in the care of patients with RA.

The results of all of these ongoing studies will further elucidate the validity of the Comprehensive ICF Core Set for RA from the perspective of different health care professions as well as feasibility in clinical practice. The findings will be discussed at an international ICF Core Set conference in 2008 and may result in a modified version of the Comprehensive ICF Core Set for RA. The current versions of the ICF Core Sets for chronic conditions, including the Comprehensive ICF Core Set for RA, and all relevant literature are available at http://www.icf-research-branch.org/research/chronicconditions.htm.


   Footnotes
 
Dr Kirchberger, Dr Stucki, and Dr Cieza provided concept/idea/research design. All authors provided writing. Dr Kirchberger provided data collection, and Dr Kirchberger and Ms Glaessel provided data analysis. Dr Kirchberger, Ms Glaessel, and Dr Cieza provided project management. Dr Stucki provided facilities/equipment. Dr Stucki and Dr Cieza provided consultation (including review of manuscript before submission). The authors thank Edda Amann and Barbara Kollerits for their valuable contribution in the linking process. They thank the following associations for their support in identifying experts: Association of Rheumatology Health Professionals; Academy for Hand Rehabilitation, Germany; The Brazil Hand Therapy Society; The British Hand Therapy Society; the national associations of physical therapists of Germany, Denmark, Finland, New Zealand, Norway, and Switzerland; and Verband Medizinischer Assistenzberufe in der Rheumatologie, Germany.

The authors also thank the participants in the Delphi exercise for their valuable contribution and their time in responding to the demanding questionnaires: Marja Arkela-Kautiainen, Martina Baumann-Hillenbrand, Ann Birch, Nina Bjoernholt Nakai, Antje Bode, Carina Boström, Ann BI Bremander, Cathy Cameron, Anne V Chadwick, Anne Christie, Anne-Cathrine Clarke-Jenssen, Janet Cushnaghan, Marc J Daniel, Ute Donhauser-Gruber, Sabine Frank, Mr Frey, Carole Fruin, Mrs Gabbert, Victoria Gall, Brenda L Greene, Helen Harcombe, Scott M Hasson, Mrs Hermann, Mrs Hochmuth, Nicoll Hödemaker, Mrs Hübner, Bente Holm, Noralee Kennedy, Mrs Kerti, Anita Kohli, Mrs Krotz, Jill Lloyd, Kerstin Mahel, Mrs Maier, Jane Martindale, Sandra Mazzanti, Elena Michelis, Nicola Moll, Salvatore Morgante, Doris Oetiker-Streit, Leda Magalhaes de Oliveira, Mrs Pallus, Sally Patterson, Jens Ole Rasmussen, Ilaria Saroglia, Dagmar Schlaubitz, Mrs Schneider, Anna Sergio, Fabrizio Sigismondi, Bente Slungaard, Fabia Sterchi, Inger H Stovgaard, Sven Christian Sutmar, Carina Thorstensson, Jane Tooby, Michael Wagner, Ragnhild Walle-Hansen, Helga Werdehausen, Astrid Werhand, Dorothee Wessinghage-Schäfler and her team, Ross Wilkie, and Mrs Woite.

A poster presentation of this research was given at the European League Against Rheumatism (EULAR) Congress; June 8–11, 2005; Vienna, Austria.

* Microsoft Corp, One Microsoft Way, Redmond, WA 98052-6399. Back

{dagger} SAS Institute Inc, PO Box 8000, Cary, NC 27511. Back


   References
Top
 Abstract
 Introduction
 Method
 Results
 Discussion and Conclusion
 References
 

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