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IDENTIFICATION OF RELEVANT ICF CATEGORIES IN PATIENTS WITH
CHRONIC HEALTH CONDITIONS: A DELPHI EXERCISE
Martin Weigl,
1,2
Alarcos Cieza,
2
Christina Andersen,
1,2
Barbara Kollerits,
2
Edda Amann
2
and Gerold Stucki
1,2
From the
1
Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians-University, Munich, Germany,
2
ICF
Research Branch, WHO FIC Collaborating Center (DIMDI), IMBK, Ludwig-Maximilians-University, Munich, Germany
Objectives: To identify the most typical and relevant
categories of the International Classification of Functioning,
Disability and Health (ICF) for patients with low back pain,
osteoporosis, rheumatoid arthritis, osteoarthritis, chronic
generalized pain, stroke, depression, obesity, chronic ischae-
mic heart disease, obstructive pulmonary disease, diabetes
mellitus, and breast cancer.
Methods: An international expert survey using the Delphi
technique was conducted. Data were collected in 3 rounds.
Answers were linked to the ICF and analysed for the degree
of consensus.
Results: Between 21 (osteoporosis, chronic ischaemic heart
disease, and obstructive pulmonary disease) and 43 (stroke)
experts responded in each of theconditions. In all conditions,
with the exception of depression, there were categories in
all ICF components that were considered typical and/or
relevant by at least 80% of the responders. While all
conditions had a distinct typical spectrum of relevant ICF
categories, there were also some common relevant categories
throughout the majority of conditions.
Conclusion: Lists of ICF categories that are considered
relevant and typical for specific conditions by international
experts could be created. This is an important step towards
identifying ICF Core Sets for chronic conditions.
Key words: outcome assessment, quality of life,
rehabilitation, activities of daily living, Delphi technique,
ICF.
J Rehabil Med 2004; suppl. 44: 12–21
Correspondence address: Gerold Stucki, Department of
Physical Medicine and Rehabilitation, University of
Munich, Marchioninistr. 15, DE-81377 Munich, Germany.
Tel: 49 89 7095 4050. Fax: 49 89 7095 8836.
E-mail: gerold.stucki@med.uni-muenchen.de
INTRODUCTION
Chronic internal, neurological, mental-health, and musculo-
skeletal conditions are among the leading causes of disability
and their contribution to disability will increase in the future.
Ischaemic heart disease, depression, cerebrovascular disease,
and obstructive lung disease are expected to be among the
top 5 leading causes of disability worldwide in 2020, and
musculoskeletal conditions are expected to be among the
leading causes of disability in developed countries (1). It is
well known that diabetes mellitus and obesity are important risk
factors for other disabling conditions such as ischaemic heart
disease and cerebrovascular disease, but they are also major
causes for disability on their own (1–3).
Each chronic condition has a typical spectrum of abilities that
may be limited. Accordingly, condition-specific health status
measures have been developed that cover important aspects of
the ability limitations that are typically limited for a specific
condition. However, since most of these measures have been
designed to measure the effects of interventions, they focus on
domains that are sensitive to change and that are relevant for
specific questions of research. Therefore, the existing health-
status measures accent different aspects of the health experience
associated with a specific condition (4).
With the new International Classification of Functioning,
Disability and Health (ICF) (5), which was endorsed by the
World Health Assembly in May 2001, and provides a common
language for functioning and health, it is now possible system-
atically to define the prototypical spectrum of functioning and
health domains for specific conditions. This is important when
defining what should be measured in an assessment of a patient.
Indeed, the inclusion of this prototypical spectrum of domains
diminishes the risk of missing any important aspects of func-
tioning and health of a patient with a specific health condition.
A possible approach to develop a set of domains that describe
the prototypical spectrum of functioning and health of a specific
health condition is the Delphi technique. The objective of this
studywastoidentifythemosttypical and relevant ICF categories
for patients with chronic musculoskeletal, neurological, mental-
health, and internal medical conditions by an international
survey of medical experts using the Delphi technique.
METHODS
Study design
A consensus-building, 3-round, e-mail survey with medical experts
using the Delphi technique was conducted. The Delphi technique, or
Delphi exercise, is a structured communication process with 4 key
characteristics: anonymity, iteration with controlled feedback, statistical
group response, and expert input (6–8). Figure 1 displays the course of
the Delphi exercise.
Twelve most burdensome chronic conditions were selected: low back
pain (LBP), osteoporosis (OP), rheumatoid arthritis (RA), osteoarthritis
2004 Taylor & Francis. ISSN 1650–1977
DOI 10.1080/16501960410015443 J Rehabil Med Suppl 44, 2004
J Rehabil Med 2004; Suppl. 44: 12–21
(OA), chronic generalized pain (Pain), stroke, depression, obesity,
chronic ischaemic heart disease (chronic IHD), obstructive pulmonary
disease (OPD), diabetes mellitus (DM) and breast cancer (BrCa).
“Chronic generalized pain”, which can be considered as a symptom
rather than as a defined disease, was selected because of its high burden
independent of the underlying pathology.
Recruitment of participants
Since the ICF was developed to facilitate communication between
different groups of people and to be usedglobally, the aim was to include
experts from all over the world, from different health professions and
physicians with different specializations. In a first step, international
societies in the fields of LBP, OP, RA, OA, pain, stroke, depression,
obesity, chronic IHD, OPD, DM and breast cancer were identified. In a
second step, representatives from the identified organizations, as well
as from partner organizations in this project (German Society for
Rehabilitation Sciences(DGRW); German, Swissand Austrian Societies
of Physical Medicine and Rehabilitation; International Society of
Physical Medicine and Rehabilitation (ISPRM); Swiss Association of
Physiotherapy; World Health Organization), were contacted and asked
to name experts for each health condition.
Data collection and measures
In the first round of the Delphi exercise open-ended, self-developed
condition specific questionnaires and information letters were sent by
e-mail to all identified experts. The questionnaires request lists of
relevant and or typical areas in the ICF components body functions, body
structures, activities and participation, and environmental factors.To
illustrate the procedure, a fraction of the questionnaire “Delphi Round 1”
for experts in stroke is shown in Fig. 2. The letter included background
information, a description of the objective of the project, the WHO
definitions of body functions, body structures, activities and participa-
tion, and environmental factors and instructions for the participants with
a detailed time line. The letters were adapted for each condition. To
clarify which kind of information was requested, an example containing
a list of relevant and/or typical body functions, body structures, activities
and participation, and environmental factors for patients with Parkin-
son’s disease was provided. The participants had 3 weeks to respond and
reminders were sent out approximately 2 days before the deadline. The
experts were not aware of the other participants in the Delphi exercise.
In the second round of the Delphi exercise the self-developed, closed-
ended questionnaire “Delphi Round 2” was sent together with corre-
sponding instructions. For each condition, the questionnaire “Delphi
Round 2” included: (i) the summary lists with all body functions, body
Fig. 1. The course of the Delphi exercise.
J Rehabil Med Suppl 44, 2004
Relevant ICF categories based on the Delphi technique 13
structures, activities and participation, and environmental factors that
were named in round 1 for the target condition; (ii) information
concerning whether the individual participant himself had considered
this ICF category as relevant and/or typical in round 1; and (iii) the
percentage of all participants that had considered this ICF category as
relevant and/or typical for the target condition. To illustrate the
procedure, a fraction of the questionnaire for experts in stroke is shown
in Fig. 3. The participants were asked to consider whether a named ICF
category is relevant and/or typical for patients with the target condition,
taking their own and the answers of the group from the first round into
account. The same experts included in the first Delphi round, as well as a
number of experts whose addresses had not been available for the first
round, were included. The participants had 2 weeks to respond, and
reminders were sent out 2 days before the deadline.
In round 3, the self-developed questionnaire “Delphi Round 3” was
sent to the participants together with corresponding instructions. The
questionnaire “Delphi Round 3” was constructed similar to the
questionnaire “Delphi Round 2”. It included the same ICF categories
as in round 2 and provided information about the individual answers in
round 2, as well as the compiled group responses in round 2 of the target
condition. Again, the participants had 2 weeks to respond, and reminders
were sent out 2 days before the deadline.
Linking of body functions, body structures, activities and participation,
and environmental factors to the ICF
The answer for four musculoskeletal conditions (LBP, OP, RA, OA)
were linked to the ICF after the third Delphi round. Based on the
experience and knowledge gathered with the Delphi exercises of the 4
musculoskeletal conditions, which were performed at the beginning, it
was possible to develop a computerized system to link the experts’
answers to the ICF and to analyse the data. This system enabled the
linking of the experts’ answers after the first Delphi-round in the
remaining 8 Delphi exercises, which could then be performed more
quickly and easily.
The linkage was performed separately by 2 trained health profes-
sionals on the basis of 10 linking rules (9). Consensus between health
professionals was used to decide which ICF category should be linked to
each answer. To resolve disagreements between the 2 health profes-
sionals concerning the selected categories, a third person trained in the
linking rules was consulted. In a discussion led by the third person, the 2
health professionals who had linked the answers stated their pros and
cons for the linking of the answer in question to a specific ICF category.
Based on these statements, the third person made an informed decision.
One of these 3 involved health professionals was always a psychologist,
1 was a medical doctor with specialization in physical medicine and
rehabilitation and the third was a psychologist, a medical doctor or a
physiotherapist.
Analyses
Descriptive statistics were used to analyse the response rates and the
personal characteristics of the participants. After each round of the
Delphi exercise, the percentage of participants that considered an ICF
category as relevant and/or typical was calculated separately for each
health condition. After the third Delphi round, the results were
summarized on the second level of the ICF by replacing third- or
fourth-level ICF categories with the overlying second-level category.
The ICF is organized in a hierarchical scheme, so that the lower-level
category shares the attributes of the higher-level category (5).
Fig. 2. Fraction of the stroke
specific Questionnaire
“Delphi round 1”.
Fig. 3. Fraction of the stroke specific questionnaire “Delphi round 2”. The first 2 columns include the ICF categories with the corresponding
codes that were named by the participants in the first round of the Delphi exercise. For the second round we assigned a code to each
participant. If a participant named a specific ICF category in round 1, he could find his code in one of the columns right from that category.
The column right from the participant’s codes shows the percentage of participants that also considered this ICF category as relevant and/or
typical in round 1. In the last column the participants were asked to respond with yes or no whether they consider this category as relevant
and/or typical for patients with stroke.
J Rehabil Med Suppl 44, 2004
14 M. Weigl et al.
Participants and response rates
Experts from 46 countries participated. Table I shows the regions of
origin of participants, their professionsand their median years of clinical
experience. The numbers of experts that responded in at least 1 Delphi
round and the corresponding response rates are also presented in Table I.
Since a few experts did not participate in all 3Delphi rounds,the number
of responders in each round is slightly smaller.
RESULTS
Relevant and/or typical ICF categories
Consensus process. The consensus process throughout the
Delphi rounds is summarized in Table II. In round 1 of the
Delphi exercise, the participants named between 137 (OP) and
300 (stroke) different ICF categories. Only a few ICF categories
had a consensus greater than 80%.
In round 2 there was over 80% agreement for relevant ICF
categories in all health conditions. Depression had the lowest
number of relevant ICF categories in round 2 (11 ICF categories
with a consensus >80%), and RA had the highest number (55
ICF categories).
In round 3, the number of ICF categories with a consensus
>80% continued to increase. Stroke (74 ICF categories) and RA
(61 ICF categories) had the highest numbers of relevant ICF
categories, and obesity (27 ICF categories) and chronic IHD (29
ICF categories) had the lowest numbers. In the summary of the
ICF categories on the second level of the ICF, the highest
numbers of relevant ICF categories were 72 in stroke and 49 in
RA, and the lowest numbers were 23 in chronic IHD and 27 in
obesity.
Results of the third round of the Delphi exercise. The ICF
categories in the 4 components considered relevant by at least
80% of the participants in 1 of the health conditions are shown in
the Tables III–VI. The categories are presented in the order of
the ICF.
In the component body functions, 43 different ICF categories
reached a consensus of 80% in at least 1 of the health conditions.
No body function reached a consensus of 80% in all health
conditions. The body functions b130 energy and drive functions,
b152 emotional functions, b280 sensation of pain, and b640
sexual functions reached a consensus of at least 80% in 8 or
more health conditions.
In the component body structures, 19 different ICF categories
reached a consensus of 80% in at least 1 of the health conditions.
No body structure had a consensus of 80% in 8 or more health
conditions.
Table I. Experts who answered in at least 1 of the 3 Delphi rounds and response rate
LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
Addressed experts (n) 51 51 53 67 98 85 91 108 225 133 414 211
Responders (n)372122293522244321212522
Experience (median in years) 19 18 19 20 20 20 19 20 20 15 13 21
Response rate (%) 73 41 42 43 36 26 26 40 9 16 6 10
Origin
West Europe 54 71 64 66 71 50 67 79 67 100 56 73
East Europe 3 5 9 3 11 9 8 5 10 0 4 9
North America 16 5 5 10 6 14 4 5 5 0 12 14
South America 0 5 0 3 0 9 4 0 0 0 4 0
Asia 11 10 14 7 6 9 13 5 10 0 24 0
Africa 5 0 5 3 3 9 0 0 5 0 0 0
Australia 11 5 5 7 3 0 4 7 5 0 0 5
Profession (%)
Physicians 81 77 87 66 60 60 67 64 81 43 64 50
PMR 30 19 23 28 26 5 4 16 33 10 12 9
Neurology 0 0 0 0 3 0 0 44 0 0 0 0
Orthopaedic surgeon 5 10 0 17 0 0 0 0 0 0 0 5
Rheumatology 24 24 55 17 0 0 0 0 0 0 0 0
Pneumology 0 0 0 0 0 0 0 0 0 19 0 0
Internal medicine 0 0 0 0 3 0 46 0 43* 0 36† 36‡
Psychiatry 0 0 0 0 9 55 4 0 0 0 0 0
Anaesthesiology 0 0 0 0 14 0 0 0 0 0 0 0
General practitioner, other physicians 22 24 9 4 6 0 13 2 5 14 16 5
Psychologists 0 0 0 0 9 18 4 2 0 0 4 14
PT or OT 19 24 5 24 29 9 17 23 14 43 20 23
Nurses 0 0 0 0 0 9 0 2 0 10 0 0
Others** 0 0 0 10 3 5 13 9 5 5 12 14
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer;
PMR = physical medicine and rehabilitation; PT = physiotherapist; OT = occupational therapist.
* 8 of 9 internal specialists in the CIHD group were specialized in cardiology.
† 6 of 9 internal specialists in the DM group were specialized in endocrinology or diabetology.
‡ 7 of 8 internal specialists in the BrCa group were specialized in oncology.
** “Others” included social workers, specialists in public health, and 1 epidemiologist.
J Rehabil Med Suppl 44, 2004
Relevant ICF categories based on the Delphi technique 15
In the component activities and participation, 44 different
ICF categories reached a consensus of 80% in at least 1 of the
health conditions. The ICF category d920 recreation and leisure
had a consensus of 80% in all 12 health conditions. In addition,
the activities and participation d430 lifting and carrying objects,
d450 walking, d540 dressing, d640 doing housework, d770
intimate relationships and d850 remunerative employment
reached a consensus of at least 80% in 8 or more health
conditions.
In the component environmental factors, 27 different ICF
categories reached a consensus of 80% in at least one of the
health conditions. The ICF categories e110 products or
substances for personal consumption (inclusion: drugs, food),
e310 immediate family, and e355 health professionals had a
consensus of 80% in all 12 health conditions. In addition, the
environmental factors e410 individual attitudes of immediate
family members, e450 individual attitudes of health profes-
sionals, and e580 health services, systems and policies reached a
consensus of at least 80% in 8 or more health conditions.
DISCUSSION
In this Delphi exercise, there was a high consensus among
experts about the most relevant and typical body functions, body
structures, activities and participation and environmental
factors in patients with chronic musculoskeletal, neurological,
mental-health, and internal-medicine disorders. The finding that,
with the exception of depression, in all conditions ICF
categories from each component had consensus levels greater
than 80% underscores the need to address body functions and
body structures, activities and participation, as well as
environmental factors when assessing functioning and health
in patients with chronic conditions.
The large differences between the relevant and typical ICF
categories across all health conditions demonstrate the need for a
condition-oriented approach when defining ICF-based tools for
clinical practice, e.g. the development of ICF Core Sets for
chronic conditions (10, 11). However, some ICF categories in
the components body functions, activities and participation, and
environmental factors are relevant in the majority of the selected
health conditions. Therefore it may be possible to define a
Generic Set of ICF categories for all chronic conditions. Indeed,
the environmental factors e310 immediate family or the
activities and participation-category d920 recreation and
leisure may be considered essential for the well-being of any
human being.
As expected, the greatest diversity between the health con-
ditionsexistsin bodystructures.Moststructures withaconsensus
above 80% are only relevant for 1 or 2 of the selected chronic
health conditions. The pattern of the consensus in the relevance
of body structures reflects the similarities of musculoskeletal
conditions with the common important body structures s750
structure of lower extremity, s760 structure of trunk, s770
additional musculoskeletal structures related to movement
(inclusion: bones, joints, muscles) and of the internal-medicine
conditions CIHD, OPD, and DM with the commonrelevant body
structure s410 structure of cardiovascular system.
In our tables we summarized the results on the second level of
the ICF to present all categories with the same degree of
precision. The method of summarizing the results on the
second level of the ICF follows the structure of the ICF that
arranges the categories so that a lower-level category shares the
attributes of the higher-level categories of which it is a member.
The use of a lower-level category automatically implies that the
higher-level category is applicable. Thus, this method does not
artificially increase the consensus in the corresponding second-
level categories.
The validity of this Delphi exercise is strengthened by the fact
Table II. The consensus process from the first to third Delphi round
Condition
LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
Round 1
ICF categories with a
consensus >80% (n)
34650203 0 003
Round 2
ICF categories with a
consensus >80% (n)
51 27 55 41 32 11 23 47 22 23 32 28
Round 3
ICF categories with a
consensus >80% (n)
60 43 61 54 48 42 27 74 29 34 57 31
Final consensus >80% for relevant ICF categories at the second level of the ICF per component
Components combined (n)423649454139277223284228
Body functions (n) 13 7 10 12 9 8 10 23 8 9 15 5
Body structures (n)447550321294
Activities and participation (n) 13 11 18 17 17 22 6 33 10 9 7 10
Environmental factors (n)1214141110981448119
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer.
J Rehabil Med Suppl 44, 2004
16 M. Weigl et al.
that different numbers of relevant ICF categories in the
components reflect different burdens of the conditions. The
largest sets of ICF categories for stroke and RA reflect the high
level of burden of these conditions. The relevant ICF categories
for stroke cover all but 1 ICF chapter of the component body
Functions and all chapters of the component activities and
participation. This demonstrates that stroke affects nearly all
facets of functioning and health. In contrast, 6 of the 8 most
Table III. International Classification of Functioning, Disability and Health (ICF) categories in the component body functions considered as
relevant by 80% of the participants in at least 1 condition
Condition
ICF categories LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
b110 Consciousness functions – – – – – – – 89 – – – –
b114 Orientation functions – – – – – – – 96 – – – –
b130 Energy and drive functions 93 – 94 91 – 100 94 93 – – 100 89
b134 Sleep functions 100 – 94 87 100 100 88 – – 89 – –
b140 Attention functions – – – – – 94 – 96 – – – –
b144 Memory functions – – – – – 88 – 100 – – – –
b147 Psychomotor functions – – – – – 94 – – – – – –
b152 Emotional functions 100 100 88 91 100 100 88 100 88 – – 100
b156 Perceptual functions – – – – – – – 100 – – – –
b167 Mental functions of language – – – – – – – 96 – – – –
b180 Experience of self and time
functions
– – 82 – – – 88 – – – – 95
b210 Seeing functions – – – – – – – 96 – – 100 –
b235 Vestibular functions – 100 – – – – – – – – – –
b260 Proprioceptive function 100 82 – – 80 – – 93 – – 100 –
b265 Touch function – – – – – – – 96 – – 89 –
b270 Sensory functions related to
temperature and other stimuli
– – – – – – – – – – 95 –
b280 Sensation of pain 100 100 100 96 100 94 88 96 94 – 89 95
b310 Voice functions – – – – – – – – – 89 – –
b320 Articulation functions – – – – – – – 89 – – – –
b410 Heart functions – – – – – – 88 86 94 94 – –
b415 Blood vessel functions – – – – – – – – 94 – 95 –
b420 Blood pressure functions – – – – – – 100 89 94 – 89 –
b435 Immunological system functions – – – – – – – – – – 89 –
b440 Respiration functions – – – – – – – – – 100 – –
b445 Respiratory muscle functions – – – – – – – – – 83 – –
b450 Additional respiratory functions* – – – – – – – – – 100 – –
b455 Exercise tolerance functions – – – – 100 – – – 100 100 89 –
b460 Sensations associated with
cardiovascular and respiratory
functions†
– – – – – – – – 100 89 – –
b510 Ingestion functions – – – – – – – 96 – – – –
b530 Weight maintenance functions 83 – – – – – – – – – 89 –
b540 General metabolic functions – – – – – – 94 – – – 100 –
b610 Urinary excretory functions – – – – – – – – – – 89 –
b620 Urination functions – – – – – – – 96 – – – –
b640 Sexual functions 93 – 94 87 96 100 81 86 88 – 94 100
b710 Mobility of joint functions 100 82 100 96 96 – 81 93 – – – –
b715 Stability of joint functions – – 94 96 – – – – – – – –
b730 Muscle power functions 100 94 100 96 100 – – 100 – 83 – –
b735 Muscle tone functions 97 – – – 84 – – 100 – – – –
b740 Muscle endurance functions 97 – – 87 – – – – – – – –
b760 Control of voluntary
movement functions
– 100 – 87 – – – 96 – – – –
b770 Gait pattern functions 86 – – 91 – – – 89 – – – –
b780 Sensations related to muscles and
movement functions (including muscle
stiffness)
100 – 100 91 – – – – – – – –
b840 Sensation related to the skin‡ – – – – – – – – – – 89 –
“–” = consensus <80% or no participant named that domain in the corresponding health condition.
* b450 additional respiratory functions are defined as functions related to breathing, such as coughing, sneezing and yawning.
† b460 sensations associated with cardiovascular and respiratory functions are defined as sensations such as missing a heart beat, palpitation
and shortness of breath.
‡ b840 sensations related to the skin are defined as sensations such as itching, burning sensation and tingling.
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis,; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer.
J Rehabil Med Suppl 44, 2004
Relevant ICF categories based on the Delphi technique 17
relevant body functions for patients with depression are
classified in the ICF chapter mental functions. Despite this
narrow field of affected body functions, the participants
considered ICF categories of all chapters in activities and
participation, with the exception of the mobility chapter, as
relevant and/or typical for patients with depression. This reflects
the high contribution to disability of depression (1). As
expected, DM and RA, health conditions that affect many organ
systems, had the largest set of relevant body structures. It is also
not surprising that LBP and chronic generalized pain shared
most of the relevant and typical body functions and activities and
participation.
The participants named between 7 (OPD) and 39 (Obesity)
different personal factors, although we did not explicitly ask
for them. Frequently named personal factors were related
to education status, profession, co-morbidities, life style,
fitness, and coping style. After the third Delphi round there
was a consensus of over 80% for some personal factors such
as “smoking” in obesity and chronic IHD, “sedentary life-style”
in CIHD, “personal attitudes about illness” in Dep, or “job
satisfaction” in Pain. The information regarding personal
factors gathered in the Delphi exercise can be helpful when
including personal factors in future revisions of the ICF coding.
The generalizability of this Delphi exercise is limited due to
the number and selection of experts. The amount of time that
was necessary to answer round one, especially if a person did not
know the concepts of the ICF before may have kept many
experts away from participating in this survey. As expected, we
had higher response rates in the musculoskeletal conditions
compared with the other conditions, because our partner
organizations were most active in the musculoskeletal fields.
Most contacted experts in internal medicine conditions had no
previous connections with our institution. In addition, it can be
assumed that experts in internal medicine conditions are less
familiar with the ICF than experts in musculoskeletal conditions
(12). The small numbers of experts in the internal medicine
conditions might have decreased the chance of detecting all
relevant ICF categories.
Although much care was taken in the selection of experts and
a wide range of medical disciplines and health professions was
achieved, no psychologist participated in the LBP exercise, no
orthopaedic surgeon participated in the RA exercise and only
one physiotherapist participated in the RA exercise. A relatively
high percentage of physiotherapists were present in the OP and
in the OPD group, however. The selection of categories, as
well as the importance accorded to some of them as reflected by
the percentage of agreement, can be underestimated or over-
estimated.
Although we tried to recruit experts from different continents
and cultures, the majority of responding experts came from
Western Europe. This may reduce the generalizability of our
results to other cultures. For example, all 4 Asian participants in
DM who answered in the secondand third Delphi rounds (2 from
Thailand, 1 from Malaysia, and 1 from Kuwait) considered the
ICF categories e320 friends, e420 individual attitudes of friends,
and e555 associations and organizational services, systems and
Table IV. International Classification of Functioning, Disability and Health (ICF) categories in the component body structures considered
as relevant by 80% of the participants in at least 1 condition
Condition
ICF categories LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
s110 Structure of brain – – – – 88 – – 100 – – – –
s120 Spinal cord and related structures 100 – – – – – – – – – – –
s140 Structure of sympathetic nervous
system
––––80––– – – 89–
s150 Structure of parasympathetic nervous
system
– – – – – – – – – – 89 –
s220 Structure of eyeball – – – – – – – – – – 94 –
s410 Structure of cardiovascular system – – 82 – – – 81 89 100 100 100 –
s420 Structure of immune system – – 94 – – – – – – – – 95
s430 Structure of respiratory system – – – – – – – – – 100 – –
s550 Structure of pancreas – – – – – – – – – – 94 –
s610 Structure of urinary system – – – – – – – – – – 89 –
s630 Structure of reproductive system – – – – – – – – – – – 100
s710 Structure of head and neck region – – – 83 92 – – – – – – –
s720 Structure of shoulder region – – 94 – – – – – – – – 84
s730 Structure of upper extremity – 89 100 96 – – – – – – – 89
s750 Structure of lower extremity 93 89 100 100 – – 88 – – – 83 –
s760 Structure of trunk 100 100 100 100 84 – – –
s770 Additional musculoskeletal
structures related to movement*
100 95 100 100 88 – 94 – – – – –
s810 Structure of areas of skin – – – – – – – – – – 88 –
s830 Structure of nails – – – – – – – – – – 94 –
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer.
* s770 additional musculoskeletal structures related to movement include e.g. joints, bones, muscles.
J Rehabil Med Suppl 44, 2004
18 M. Weigl et al.
policies as important, but the consensus level of West-European
participants for the relevance of each of these three categories
was only 64%. The ICF category e430 individual attitudes of
people in positions of authority was judged as typical and/or
relevant by 75% of Asian participants in DM vs only 9% of
European participants. These results underscore the importance
of including different parts of the world and different cultures in
the development of ICF-based practical tools.
This study is an important step towards identifying Core Sets
of ICF categories that can be used across chronic health
conditions. Since the results of any consensus process may
differ with different group of experts, further studies to improve
the reliability and generalizability of these results are in
progress. Nonetheless, the involvement of the opinions of
international experts from different health professions in the
ICF Core Sets development process is likely to increase the face
validity and the acceptance among health professionals of future
ICF Core Sets.
Table V. International Classification of Functioning, Disability and Health (ICF) categories in the component activities and participation
considered as relevant by 80% of the participants in at least 1 condition
Condition
ICF categories LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
d163 Thinking – – – – – 100 – – – – – –
d166 Reading – – – – – – – 100 – – – –
d170 Writing – – 100 – – – – 96 – – – –
d175 Solving problems – – – – – 100 – 85 – – – –
d177 Making decisions – – – – – 100 – – – – – –
d210 Undertaking a single task – – – – – – – 85 – – – –
d230 Carrying out daily routine – – – – – 94 – 96 94 – – 89
d240 Handling stress and other
psychological demands
83 – – – 92 83 – – 82 – – –
d310 Communicating with – receiving –
spoken messages
– – – – – – – 100 – – – –
d315 Communicating with – receiving –
non-verbal messages
–––––––89– –––
d330 Speaking – – – – – 89 – 100 – – – –
d335 Producing non-verbal messages – – – – – 83 – 96 – – – –
d350 Conversation – – – – – 94 – 93 – – – –
d410 Changing basic body position 100 – – 100 84 – – 96 – – – –
d415 Maintaining a body position 100 100 – 91 80
d420 Transferring oneself – – – – – – – 93 – – – –
d430 Lifting and carrying objects 100 100 100 96 96 – – 96 82 – – 89
d440 Fine hand use – – 100 91 – – – 100 – – – –
d445 Hand and arm use – – 100 – – – – 93 – – – 100
d450 Walking 93 100 100 96 90 – 88 100 94 100 83 –
d455 Moving around (including climbing) 100 83 94 100 – – – – 100 100 – –
d460 Moving around in different
locations
–––––––93– –––
d470 Using transportation 90 83 100 96 84 – 81 100 – – – –
d475 Driving – – 100 96 80 – – 85 – – – –
d510 Washing oneself 93 94 94 96 – 83 – 100 – 94 – –
d520 Caring for body parts – – – – – 83 – 89 – – 89 –
d530 Toileting – – 100 91 – – – 100 – – – –
d540 Dressing 93 89 100 100 88 94 81 100 – 100 – 84
d550 Eating – – 100 – – 100 88 96 – – 82 –
d560 Drinking – – – – – 89 – 100 – – – –
d570 Looking after one’s health – – – – 88 100 94 – 88 – 100 –
d620 Acquisition of goods and services – 94 100 96 88 – – 82 – 89 – –
d630 Preparing meals – – 100 – – 94 – 93 – – 94 –
d640 Doing housework 97 100 100 96 92 94 – – 88 100 – 95
d660 Assisting others – – – – – – – – – – – 84
d710 Basic interpersonal interactions – – – – – 83 – 85 – – – –
d760 Family relationships – – – – 88 89 – 93 – – – 95
d770 Intimate relationships 87 – 94 – 92 100 – – 100 94 81 95
d845 Acquiring, keeping and
terminating a job
– – – – 84 – – – – – – –
d850 Remunerative employment 100 – 100 96 92 89 – 89 82 94 – 89
d860 Basic economic transactions – – – – – – – 85 – – – –
d870 Economic self-sufficiency – – – 87
d910 Community life – 89 – 87 96 100 – 93 – – – –
d920 Recreation and leisure 97 100 100 96 100 100 94 93 88 100 100 95
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer.
J Rehabil Med Suppl 44, 2004
Relevant ICF categories based on the Delphi technique 19
ACKNOWLEDGEMENTS
We thank the participants in the Delphi exercise for their
valuable contribution and their time in responding to the
demanding questionnaires (in alphabetical order, sorted by health
condition):
Rheumatoid arthritis: Berliner M, Betteridge N, Boers M, Bolze
K, Cimmino M, Cooke, Darmavan J, da Silva J, Fuchs D, Balint G,
Hanada E, Ju
¨
rgens B, Kvien T, Langenegger T, Li L, Mengxue Y,
Mody GM, Rasker J, Symmons D, Venalis A, Wollheim F, Yelin E.
Osteoarthritis: Agel J, Akesson K, Amadio P, Bellamy N, Bijlsma
JW, Brown P, Chopra A, Dieppe P, Dreinhoefer K, Ebenbichler G,
Gutenbrunner C, Guzman JM, Huber EO, Jochums I, Kerkour K,
Knahr K, Krismer M, Kullmann L, Lohmander S, Ogunlade SO,
Rabou A, Ramar S, Roos E, Seidel E, Swoboda W, Sziraki E, Walsh
N, Wise F, Zimmer S.
Osteoporosis: Bellamy N, Bischoff H, Bodmer E, De Brito CM,
Busch B, Davies-Knorr P, Euller-Ziegler L, Heinemann E, Korda
J, Kosmu
¨
tzky G, Melvin J, Natvig B, Omar S, Probst-Eder G, Raab
C, Rembo S, Schwarzkopf S, Singh V, Stauffacher M, Stoll T,
Woolf A.
Chronic generalized pain: Aelger B, Basler HD, Berry E, Beyer
A, Blank S, Bodmer E, Ferber-Busse B, Cojokaru, Davies-Knorr P,
Dickson H, Essmann, Gureje O, Ha¨rter M, Hengeveld E, Ja¨ckel
WH, Koorits U, Kubben P, Langendoen-Sertel J, Mu
¨
ller U, Mungiu
O, Neumayer S, Panchaud C, Papadimitrakis A, Raab C, Riberto M,
Romao J, Scho¨ps P, Sciupokas A, Seeger D, Sessle B, Stoll T,
Steinberger M, Walsh N, Walti M, Yucel A.
Low back pain: Badorrek H, Blank S, Braun J, Bruusgard D,
Cooke, de Bie R, De Groot J, Disler P, Dziri C, Ehrlich G,
Faraj M, Fialka-Moser V, Gurevich D, Halpern M, Heigl-Bartussek
F, Hengeveld E, Hueppe A, Huwiler H, Jadid M, Jaeckel WH,
Kamen L, Katz J, Khan Fa, Khan Fe, Knuesel O, Luyckx K,
Mu
¨
ller U, Nordin M, Paternostro T, Piyapat P, Ruhland S, Van
Der Heijde D, van der Linden S, Walsh N, Winkelmann A,
Yamamoto H.
Depression: Battistella L, Espinoza, Faller H, Gureje O, Heeren
T, Hillert H, Hoßner B, Kanba S, Koch U, Kosza I, Kroener-Herwig
Table VI. International Classification of Functioning, Disability and Health (ICF) categories in the component environmental factors
considered as relevant by 80% of the participants in at least 1 condition
Condition
ICF categories LBP OP RA OA Pain Dep Ob Stroke CIHD OPD DM BrCa
e110 Products and substances for personal
consumption (inclusion: drugs, food)
83 100 100 100 92 94 94 89 88 100 100 95
e115 Products and technology for personal use
in daily living
93 94 100 100 – – – 96 – 83 89 –
e120 Products and technology for personal
indoor and outdoor mobility and transportation
– 100 – 87 – – – 100 – – – –
e135 Products and technology for employment 100 – 100 – – – – – – – – –
e140 Products and technology for culture,
recreation and sport
–83–––––– ––––
e150 Design, construction and building products
and technology of buildings for public use
– – 100 96 – – – 86 – – – –
e155 Design, construction and building products
and technology of buildings for private use
–8994––––89––––
e225 Climate – – – – – – – – – 100 – –
e260 Air quality – – – – – – – – – 100 – –
e310 Immediate family 100 100 100 96 100 100 88 100 100 100 100 95
e320 Friends – 83 – – 88 – – 82 100 – – 89
e325 Acquaintances, peers, colleagues, neighbours
and community members
–89–––––– ––––
e340 Personal care providers and personal assistants – 83 88 91 – – – 96 – – 95 –
e355 Health professionals 100 100 100 96 96 94 88 96 100 94 100 100
e410 Individual attitudes of immediate family
members
100 89 94 96 96 100 94 100 – 89 95 100
e420 Individual attitudes of friends – – 94 – 92 88 88 – – – 84 100
e425 Individual attitudes of acquaintances, peers,
colleagues, neighbours and community members
97 – 100 – – 88 – – – – – 84
e430 Individual attitudes of people in positions
of authority
– ––– 80––– – – ––
e450 Individual attitudes of health professionals 100 89 100 96 84 82 81 89 – – 95 100
e460 Societal attitudes – – – – – 88 81 – – – – –
e465 Social norms, practices and ideologies 90 – – – – – – – – – – –
e540 Transportation services, systems and policies – – 94 96 – – – 89 – – – –
e570 Social security services, systems and policies 93 – – 87 80 – – 86 – – 89 –
e575 General social support services, systems
and policies
– 100 – – – – – – – – – –
e580 Health services, systems and policies 100 100 100 96 100 88 94 96 – 100 100 89
e585 Education and training services, systems and
policies
– –––– ––– – – 94–
e590 Labour and employment services, systems and
policies
93–––– ––– – – ––
LBP = low back pain; OP = osteoporosis; RA = rheumatoid arthritis; OA = osteoarthritis; Pain = chronic generalized pain; Dep = depression;
Ob = obesity; CIHD = chronic ischaemic heart disease; OPD = obstructive pulmonary disease; DM = diabetes mellitus; BrCa = breast cancer.
J Rehabil Med Suppl 44, 2004
20 M. Weigl et al.
B, Montenegro R, Nusrat R, Panchaud C, Portenier L, Ragaisis K,
Ruiz P, Rybakowski, Sidandi P, Smets T, Su
¨
ß H, Witschi T.
Obesity: Adam O, Beno I, Berry E, Daansen P, De Bie R, Bray H,
Filozof C, Fogelman, Hoek W, Huber E, James P, Kriketos A,
Ludvic B, Tendera EM, Niedermann K, Retterstol L, Ru
¨
ddel H,
Shuji I, Toenissen A, van Baak M, van Hoecken D, Waldeck E,
Wirth A, Wiezorek M, Zelissen P.
Stroke: Beer S, Bogousslavsky J, Bovendeerdt T, Brunner H,
Disler P, Fries W, Frommelt P, Good D, Grimby G, Gro¨tzbach H,
Habermann, Harbich T, Hirt L, Ilmberger J, Khan F, Knorr H,
Ko¨hler F, Kool J, Luyckx K, Marincek C, Nachtmann, Panchaud C,
Portenier L, Pott C, Rabou A, Rauch A, Ring H, Seneghini A,
Spranger, Stelzer J, Sunnerhagen KS, Schmitt K, Swoboda W,
Thilmann, Tonin P, Wade D, Wallesch, Wesseloh A, Wilke S,
Worrall L, Yatsu F.
Chronic ischaemic heart disease: Aideitis A, Aroney C, Brueren
S, Deeg P, Fialka-Moser V, Gehring J, Harder M, Larsen M,
Lehmkuhl H, Li L, Ogola E, Patika J, Quittan M, Rauch A,
Rondinelli R, Tendera M, van Hanen H, Voigt-Radloff S, Westhoff
M, Winkelmann A, Yildirimakin C.
Obstructive pulmonary disease: Albiez A, Braxenthaler M, Berck
H, Dalla Lana K, Davies-Knorr P, Delgado L, Freeman D, Grimby
G, Hellmann A, Kerschl J, Merz P, Mudrich J, Mu
¨
ller C, Portenier
L, Price D, Repschla¨ger U, Ryan D, Scullion J, Stucki A, Langer D,
Wever D.
Diabetes mellitus: Abdella N, Angst F,Beaufort C, Casu A, Eandi
M, Finger M, Guo-qing H, Kapur A, Larsen J, Keel B, Montero J,
Niedermann K, Osokina I, Ostermeier S, Popovic J, Raab C, Rau B,
Ravens-Sieberer, Soliz P, Songini M, Sriswadi G, Tombek A, Wilke
S, Zaliha O.
Breast cancer: Brach M, Cole A, Delorme S, Ellerin BE, Fa¨ssler
M, Ghilezan N, Hauser C, Henderson C, Hu
¨
llemann B, Lauper M,
Marcos AF, Mosconi P, Nutu D, Pouget-Schors D, Sauer HJ,
Schwartz AL, Schwarzkopf S, Stamm T, Sellschopp A, Sonderegger
A, Stegner S, Zurbriggen G.
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