Abstract
Background The Comprehensive ICF Core Set for Multiple Sclerosis (MS) is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in the functioning of people with MS.
Objectives The objective of this study was to validate the Comprehensive ICF Core Set for MS from the perspective of physical therapists.
Design A 3-round survey based on the Delphi technique was used.
Methods Physical therapists experienced in the management of MS were asked about problems and resources of people with MS as well as environmental aspects treated by physical therapists (eg, use of assistive devices, support). Statements were linked to the ICF and compared with the Comprehensive ICF Core Set for MS.
Results Eighty physical therapists from 23 countries mentioned 2,133 issues that covered all of the ICF components. Two hundred thirty-eight ICF categories were linked to the statements. Forty-six categories in the Comprehensive ICF Core Set for MS were confirmed by physical therapists at the same level or a more specific level of classification. Nineteen additional ICF categories were reported by at least 75% of the participants.
Conclusions The results of this study support the content and face validity of the Comprehensive ICF Core Set for MS. Areas of functioning and health that physical therapists believe should be assessed were identified. The findings of this study as well as the results of completed and ongoing validation studies will further elucidate the validity of the Comprehensive ICF Core Set for MS from different perspectives.
Multiple sclerosis (MS) is associated with a wide range of impairments in body functions, including motor deficits such as muscle weakness, changes in muscle tone, ataxia, and abnormal balance, and sensory deficits. In addition, fatigue, pain, bladder and bowel dysfunction, cognitive and emotional problems, vision problems, speech and swallowing disorders, and sexual dysfunction can affect people with MS.1 These impairments vary widely in a given individual and from individual to individual over the course of the disease. They are strongly associated with limited performance of activities of daily living, restricted participation in social activities, and reduced quality of life in people with MS. The inability to work and premature retirement in young and middle-aged adults are important socioeconomic consequences of MS.2,3
Coping with such decrements in functioning requires multidisciplinary treatment and neurorehabilitation involving various health care professionals, such as physicians, nurses, physical therapists, occupational therapists, psychologists, neuropsychologists, and speech and language therapists.1,4–12 As part of a neurorehabilitation team, physical therapists have an important role in the rehabilitation of motor-related symptoms in people with MS.8,11,13–16 The main aims in neurorehabilitation are improving patients' functioning and encouraging them to deal with limitations in physical activities and restrictions in participation.8,11,14–16 The optimal management of MS-related functional limitations requires in-depth understanding, systematic consideration, and sound description and measurement of the consequences of MS.17 Although different health care professionals frequently have their own professional models of rehabilitation, a common framework is helpful for communicating about the functional limitations of people with MS, rehabilitation goals, and interventions applied.18 The International Classification of Functioning, Disability and Health (ICF), which represents such a framework, is being increasingly taken into account by health care professionals in multidisciplinary settings.19,20
For application of the ICF to the needs of people with MS, the Comprehensive ICF Core Set for MS was developed through a multistage, evidence-based, and established decision-making process that included 4 preparatory studies (systematic literature review, qualitative study, expert survey, and empirical study) and an international consensus conference.2
The Comprehensive ICF Core Set for MS includes as few categories as possible to be practical and as many as necessary to sufficiently cover the prototypical spectrum of limitations in functioning experienced by people with MS. It comprises 138 categories and is currently being validated. One key aspect is validation from the perspective of future users. Because the Comprehensive ICF Core Set for MS should serve as a standard for multidisciplinary description and assessment of functioning,21 it is important to ascertain whether the ICF categories included in it cover patients' problems addressed by health professionals' specific interventions in a multidisciplinary team including physical therapists. Moreover, validation from the perspective of health care professionals will contribute to the worldwide acceptance and credibility of the Comprehensive ICF Core Set for MS.
The objective of this study was to validate the Comprehensive ICF Core Set for MS from the perspective of physical therapists experienced in the treatment of people with MS. The specific aims were to identify problems and resources of people with MS as well as environmental aspects treated by physical therapists and to explore to what extent these aspects are represented in the Comprehensive ICF Core Set for MS.
Method
Study Design
An international 3-round e-mail survey based on the principles of the Delphi technique was conducted with physical therapists. The Delphi technique is basically defined as a method for collecting information about an issue or probable event to be used as a basis for planning and decision making.22 Its purpose is to gain consensus from a panel of informed people who have knowledge about the specific area being investigated.23
Participants
Several strategies were used to recruit experts from around the world. Members of the World Confederation for Physical Therapy and cooperation partners from the ICF Research Branch were contacted. In addition, physical therapists were identified by a literature search and by recommendations from previously recruited physical therapists (snowball system).24 The recruited experts were not involved in earlier stages of the development of ICF Core Sets for MS (expert survey and consensus conference).
To ensure that the participants in the study were knowledgeable about MS rehabilitation, the initial information letter stated that participants should be “physical therapists experienced in the treatment of people with MS.”
The first contact included an invitation to cooperate and detailed descriptions of the project, the Delphi process, and the time line.
Procedure
Initially, an open-ended questionnaire inquiring about problems and resources of people with MS as well as environmental aspects treated by physical therapists was used to obtain an overview of physical therapy intervention categories. In addition, the participants' expertise was documented by self-report on professional background, including current professional activity and specialty, as well as duration of professional and practical experience in the treatment of people with MS.
Data Collection
In round 1 of the Delphi exercise, the information letter and the questionnaire were sent to the participating physical therapists. The participants had 3 weeks to return their responses. Reminders were sent 1 week and 2 days before the deadline. The physical therapists' statements in round 1 were linked to the most closely related ICF categories according to standardized and established linking rules.25,26 Hence, the physical therapists' statements were assigned to categories in the following components: body functions (designated with the letter “b”), body structures (designated with the letter “s”), activities and participation (designated with the letter “d”), and environmental factors (designated with the letter “e”). In the ICF, the letters used for the components are followed by 1 digit representing the chapter number, a code for the second level (2 digits), and codes for the third and fourth levels (1 digit each). For example, in the designation b28014, b indicates the component body functions, 2 indicates sensory functions and pain (ICF chapter), 80 indicates sensation of pain (second-level ICF category), 1 indicates pain in body part (third-level ICF category), and 4 indicates pain in upper limb (fourth-level ICF category).
Within each classified component, the ICF categories are hierarchically arranged in a stem/branch/leaf scheme.19 Consequently, a higher-level (more specific) category includes the lower-level categories of which it is a member. Thus, the use of a higher-level category implies that the lower-level categories are applicable but not vice versa.20 Statements that were not sufficient to make a decision about the most closely related ICF categories were assigned the designation “nd” (not definable). If a statement was considered to represent a personal factor, as defined in the ICF, the concept was assigned the designation “pf.” If a statement could not be linked to the ICF, it was assigned the designation “nc” (not covered). If a statement referred to a health condition, it was assigned the designation “hc” (health condition).
Two physical therapists (A.C. and H.S.) linked all statements made by the participants independently according to the linking rules. These health care professionals were thoroughly trained on the ICF and the linking rules in a 1-week workshop conducted by team members of the ICF Research Branch in Munich, Germany. In addition, both physical therapists had practical experience in neurorehabilitation, especially in the treatment of people with MS.
The linking results from the 2 physical therapists were compared, and consensus was used to decide which ICF category should be linked to each statement made by a participant. Disagreement was resolved through a structured discussion with a third expert (M.C., a psychologist who is a team member of the ICF Research Branch) to create a final agreed-upon list of linked ICF categories.
In round 2, the participants received a list of the ICF categories linked to the answers from round 1 as well as a summary of statements assigned the designations “pf,” “nc,” “nd,” and “hc.” The physical therapists were asked, “Do you agree that these ICF categories represent problems and resources of people with MS as well as environmental aspects treated by physical therapists?” The answers were descriptively analyzed.
In round 3, the participants received a list of the ICF categories linked to the group answer from round 2 (percentage of “yes” answers) and their own answers as well as a summary of statements not linked to ICF categories. The participants were then asked whether these categories represent problems and resources of people with MS as well as environmental aspects treated by physical therapists; they were asked to considered the group answer in their final decision (Figure).
Description of the Delphi exercise. ICF=International Classification of Functioning, Disability and Health; MS=multiple sclerosis.
Data Analysis
Descriptive statistics were used to characterize the sample and the linked ICF categories from rounds 2 and 3. Kappa statistics with bootstrapped 95% confidence intervals were calculated by using SAS for Windows version 9.1 (SAS Institute Inc, Cary, North Carolina) to analyze the agreement between the 2 health care professionals who performed the linking.27,28 Kappa coefficient values can be negative but generally vary from 0 to 1; 1 indicates perfect agreement and 0 indicates no additional agreement beyond what is expected by chance alone. The degree of agreement was determined as described by Landis and Koch.29
The identified ICF categories (physical therapy intervention categories) were compared with the ICF categories included in the Comprehensive ICF Core Set for MS. Two sets of ICF categories were extracted: confirmed ICF categories and additional ICF categories. An ICF category was considered to be confirmed if the same physical therapy intervention category was included in the Comprehensive ICF Core Set for MS at the same level or a higher level. For example, the second-level category d415 (maintaining a body position) was considered to be confirmed because at least 1 third-level (higher-level) category (eg, d4153 [maintaining a sitting position]) included in it reached a level of agreement above 75%. An ICF category that had a level of agreement of more than 75% but was not included in the Comprehensive ICF Core Set for MS was considered to be an additional ICF category. To calculate the percentage of agreement for less specific (lower-level) ICF categories, the more specific (higher-level) ICF categories contained in them were taken into account. The final decision about the inclusion of additional ICF categories will be made on the basis of the results of this study and other validation studies and will include integration of the perspectives of other health professionals and statistical analyses.
The 75% agreement cutoff was used in previous studies on the validation of ICF Core Sets for stroke, osteoarthritis, rheumatoid arthritis, and others.30–33 Using the same cutoff in various studies makes it possible for researchers to compare the results across studies.
Role of the Funding Source
This study was part of the project “Development of ICF Core Sets for MS” and was funded by the Gemeinnützige Hertie-Stiftung (1.01.1/06/008).
Results
Participants
One hundred fifty-three physical therapists were initially contacted. Ninety-one of them, representing 23 countries, agreed to participate in the Delphi study. Finally, 80 physical therapists (52.3%) responded to round 1 and returned the questionnaire. The demographic and professional characteristics of the participants in round 1 are shown in Table 1. The questionnaire used in round 2 was sent to all participants from round 1 and was answered by 74 physical therapists (92.5%). Seventy-one of those 74 physical therapists (95.9%) participated in round 3, for an overall response rate of 78.0% (71/91). Attrition between rounds was due to changed e-mail addresses and no answer despite 3 reminders.
Demographic and Professional Characteristics of the Participants
Identified ICF Categories
In round 1, the participants provided 2,133 statements referring to problems and resources of people with MS as well as environmental aspects treated by physical therapists. These statements were linked to 238 ICF categories: 91 body functions categories (41 second-level categories, 45 third-level categories, and 5 fourth-level categories), 7 body structures categories (2 second-level categories and 5 third-level categories), 86 activities and participation categories (43 second-level categories and 43 third-level categories), and 54 environmental factors categories (34 second-level categories and 20 third-level categories). The percentages of agreement among the participants in rounds 2 and 3 regarding these ICF categories are shown in Tables 2, 3, and 4. In addition, several statements were assigned the designations “pf,” “nc,” and “hc.”
Physical Therapy Intervention Categories for Multiple Sclerosis in the ICF Components Body Functions and Body Structuresa
Physical Therapy Intervention Categories for Multiple Sclerosis in the ICF Component Activities and Participationa
Physical Therapy Intervention Categories for Multiple Sclerosis in the ICF Component Environmental Factorsa
The kappa statistic for linking was 0.72 (95% confidence interval=0.71–0.73). This result for the accuracy of peer review is comparable to those in other studies reporting kappa statistics for the linking of categories31,33 and can be regarded as indicating substantial agreement, as described by Landis and Koch.29
Confirmed ICF Categories
Forty-six categories in the Comprehensive ICF Core Set for MS were confirmed by the physical therapists at the same level or a more specific level of classification (Tab. 5). Thirty-one percent of the ICF categories in the Comprehensive ICF Core Set for MS were confirmed by the physical therapists at the same level; that is, 19 body functions categories, 18 activities and participation categories, and 6 environmental factors categories in the Comprehensive ICF Core Set for MS were confirmed at the same level of classification. In addition, 6 categories were identified at a more specific level (higher level); these represented 3 categories in the Comprehensive ICF Core Set for MS (eg, d4153 [maintaining a sitting position] representing d415 [maintaining a body position]).
Summary of the Results
Additional ICF Categories
Forty-nine ICF categories were identified as additional ICF categories that were not included in the Comprehensive ICF Core Set for MS. Nineteen of them at the second and third levels were agreed upon by more than 75% of the physical therapists (Tab. 5).
Most of the statements assigned the designation “pf” addressed attitudes that may affect the ability of people with MS to manage problems and resources associated with MS in a positive or negative way. Some statements assigned the designation “pf” referred to coping/learning strategies (98.6%), trainability (94.4%), self-consciousness/self-confidence/self-esteem/self-efficacy (87.3%), and lifestyle and habits (85.9%).
Furthermore, several statements assigned the designation “nc” were agreed on by at least 75% of the physical therapists. The participants stated that compensatory movements, prevention and management of falls and other complications, goal setting, hydrotherapy, and walking and movement speed were among the important physical therapy intervention categories.
Finally, statements assigned the designation “hc” referred to acute injuries, osteoporosis, scoliosis, chest infection, and chronic obstructive pulmonary disease.
Discussion
In the present study, a broad range of problems and resources of people with MS as well as environmental aspects treated by physical therapists were identified with the Delphi technique. Categories of the Comprehensive ICF Core Set for MS, particularly those in the components body functions and activities and participation, were confirmed from the perspective of physical therapists experienced in the treatment of people with MS. In addition, several physical therapy intervention categories that were not included in the current version of the Comprehensive ICF Core Set for MS were identified.
Most body functions categories included in the Comprehensive ICF Core Set for MS were confirmed by the participating physical therapists at the same level or a more specific level of classification. Two of the main problems of people with MS, judged by physical therapists to be clinically important for mental health and general health status34—namely, b1308 (energy and drive functions, other specified [fatigue]) and b455 (exercise tolerance functions)—were confirmed by the physical therapists as intervention targets. Many studies have explored the effects of interventions provided by physical therapists to address fatigue and have confirmed that physical therapists frequently treat problems related to fatigue and cardiovascular fatigability.35–45
Problems in neuromusculoskeletal and movement-related functions, such as joint mobility, muscle power, muscle endurance, and muscle tone, are among the main intervention targets in physical therapy, and these functions were reported as outcomes in several investigations.8,39,46–59 Weakness in the legs, which is covered by category b730 (muscle power functions) and which has a great impact on the activities of people with MS, also was confirmed as an intervention target in physical therapy.40,49
Function-improving physical therapy, including training of remaining motor functions, avoidance of muscle, tendon, or joint contractures, improvement of postural control, and education of people with MS, is a primary intervention, confirming category b735 (muscle tone functions).60–62
Some body functions and activities and participation categories included in the Comprehensive ICF Core Set for MS, such as b620 (urination functions) and d415 (maintaining a body position), were confirmed by the participants at a more specific level of classification. This finding is not surprising because optimizing urinary continence63,64 and specific mobility-related activities, such as sitting and standing,65–67 is a core domain of physical therapy. It is well known that exercise therapy, which focuses on the improvement of muscular strength, has a positive effect on activities such as transfers,57 walking,37,48,55,68–70 household maintenance, housework, and gardening. However, further evidence of the interrelationships of functional problems, effective rehabilitation interventions, and performance of daily activities is needed.14,16,71,72 The present study also showed that another important physical therapy intervention aim for people with MS is the improvement of fine motor control of the hand (d440),44 which is strongly associated with the ability of people with MS to work.73
The present study also revealed the importance of environmental factors in physical therapy rehabilitation. The participants confirmed most of the environmental factors categories included in the Comprehensive ICF Core Set for MS, such as e120 (products and technology for personal indoor and outdoor mobility and transportation). They indicated that knowledge of or recommendations for assistive products and technology are essential for people with MS.15,72,74,75
In total, the participants mentioned several categories that were not included in the Comprehensive ICF Core Set for MS. A high level of agreement among the physical therapists was reached for some of these categories. From clinical practice, it is known that the body image of people with MS (b1801) is an important intervention target. However, in research, this issue is primarily addressed by psychotherapists.76–78 In this context, a positive body image seems to be associated with less depression and a strengthening of self-confidence.78 Further physical therapy–related research is needed to explore the effects of body image–targeted interventions provided by physical therapists.
The participants clearly agreed that categories b440 (respiration functions), b4402 (depth of respiration), and b450 (additional respiratory functions) represent relevant categories treated by physical therapists. Training of the accessory respiratory muscles and specific breathing therapy are important interventions in physical therapy rehabilitation, influencing functions such as general respiration and the depth of respiration. Several studies have indicated that physical therapy interventions, including breathing exercises, seem to prevent secondary complications (infections) and improve breathing function.79–83 Therefore, the inclusion of these categories in the final version of the Comprehensive ICF Core Set for MS should be considered.
Statements referring to trunk stability, core stability, balance, joint and postural alignment, postural control, and trunk control were linked to the ICF categories b715 (stability of joint functions), b755 (involuntary movement reaction functions), b760 (control of voluntary movement functions), and b765 (involuntary movement functions). Impaired balance and resulting disturbances in maintaining, achieving, or restoring a state of balance during a posture or activity84 are common problems and are the main incapacitating body functions assessed in people with MS and treated by physical therapists.14,16,65–67,72,85–90 The maintenance of postural stability depends on a continuous flow of information from the visual, vestibular, and somatosensory systems and contributes to adequate balance.84
Three additional categories of the component body structures were identified: s7104 (muscles of head and neck region), s7701 (joints), and s7702 (muscles). Physical therapy is commonly recommended to improve the physical functioning of joints and muscles, implying effects on the respective body structures.88 In addition, hands-on therapy is applied when necessary to enhance the mobility and stability of joint functions or to optimize muscle tone functions.88
The category d435 (moving objects with lower extremities) was identified as an additional activities and participation category. From the literature it is known that coordinated actions in exercise therapy, such as moving ankle weights during leg extension exercises57 and pushing pedals on a bicycle35 or in a car, improve the capacity to move objects with the lower extremities. Thus, it is not surprising that this ICF category was named by the participants in the present study.
Most of the participants also agreed that categories e140 (products and technology for culture, recreation, and sport) and e1401 (assistive products and technology for culture, recreation, and sport) represent aspects of the environment relevant for physical therapists treating people with MS. This notion is not specifically discussed in the literature, but clinical experience has shown that physical therapists often provide advice about which products and technologies are suitable for recreation and sports. In line with this finding, the National Clinical Guideline for diagnosis and management recommends that people with MS receive assistive technology and equipment to remain independent and to improve their quality of life.13
In addition to the above-mentioned categories, a considerable number of the participants' statements were identified as representing personal factors, such as coping and dependency upon other people and devices. The coping strategies of people with MS influence the outcomes of physical therapy interventions and, consequently, physical functioning.91
It is interesting that several issues relevant for physical therapists treating people with MS but not covered in the ICF were identified. One of these issues was the prevention and management of falls and other complications. It is important to quantify the risk of falls in people with MS and to minimize and prevent falls in people with MS through specific physical therapy approaches.92–94 Another identified issue not covered in the ICF was walking and movement speed. The ICF category d450 (walking) focuses on walking distance in its third-level categories (eg, d4501 [walking long distances]). Walking and movement speed, however, is not specified in these categories. Romberg et al reported that walking speed seems to be a key indicator of general mobility even in the early stage of MS.55
It is important that the majority of the issues not covered in the ICF did not refer to functioning and disability as defined by the ICF. They mainly referred to complex intervention strategies (such as compensatory movements, prevention and management of falls and other complications, goal setting, and hydrotherapy), which are not categories of functioning. However, other issues, such as walking and movement speed, are potentially missing categories that may be included in the ongoing process of updating the ICF.
It is important that the 92 categories in the Comprehensive ICF Core Set for MS that were not confirmed by the physical therapists participating in the present study are categories that are usually treated by other health care professionals, such as (neuro)psychologists (eg, b114 [orientation functions] and b126 [temperament and personality functions]), speech and language therapists (eg, b310 [voice functions] and b330 [fluency and rhythm of speech functions]), occupational therapists (eg, d510 [washing oneself] and d520 [caring for body parts]), and social workers (eg, e555 [economic services, systems, and policies] and e570 [social security services, systems, and policies]).
The Comprehensive ICF Core Set for MS serves as a pool of categories for describing functioning in settings in which the comprehensive multidisciplinary description and assessment of functioning are necessary.2 The results of the present study contribute to the validity of the ICF categories included in the Comprehensive ICF Core Set for MS. The present study can be the starting point for further studies focusing on the identification of adequate outcome measures for assessing the ICF categories covered in the Comprehensive ICF Core Set for MS. Therefore, it is important to develop strategies for the implementation of the Comprehensive ICF Core Set for MS in clinical practice.
The Comprehensive ICF Core Set for MS can be integrated in the physical therapy treatment of people with MS to facilitate goal setting and the assignment of intervention targets to specific interventions, to document intervention goals in a standardized way, and to evaluate goal achievement.95,96 When used by health care professionals in a multidisciplinary team, the Comprehensive ICF Core Set for MS emphasizes the core competencies of various health care professions and facilitates interprofessional communication. Therefore, the Comprehensive ICF Core Set for MS might serve as a common platform from which various professionals could start their assessments and interventions and to which they could return when discussing the treatment of patients and intervention goals. It also is possible to select further ICF categories for specific decrements in the functioning of individual patients. In this way, the treatment of people with MS could be tailored to their specific needs.
The present study had some limitations. Participants from 5 World Health Organization regions were recruited and completed the Delphi survey, guaranteeing a wide range of expert opinions. However, the external validity was limited because of an underrepresentation of physical therapists from the Southeast Asian, Eastern Mediterranean, and African regions. This underrepresentation occurred because of the lower prevalence of MS in these regions. This underrepresentation also could be explained by limitations in Internet accessibility, problems with the English language, or the lack of a developed network of physical therapists experienced in the treatment of people with MS.
Unfortunately, a reduction in the number of participants in the Delphi rounds could not be prevented. The main reasons seemed to be the considerable workload, the effort involved in completing the Delphi survey, and the duration of the data collection in the 3 rounds. Nevertheless, compared with those in similar studies, the overall response rate of 78.0% (71/91) can be considered high.32,33
The linking process was performed by 2 physical therapists according to established linking rules. However, it remains unclear whether other health care professionals would have made different decisions.
A further limitation concerned the 75% cutoff for the consensus of the participants. Although this cutoff was used in previous studies on the validation of ICF Core Sets, it still remains, to some extent, arbitrary. Keeney et al recommended a threshold of 75% as “the minimal level” of consensus to be applied in Delphi studies.97 However, we are aware that a higher cutoff (eg, 90%) would have generated few agreed-upon categories, whereas a lower cutoff (eg, 60%) would have generated more.
It is important that the present study focused only on the content and face validity of the Comprehensive ICF Core Set for MS. We envision that the results of other validation studies will be integrated to create a final version of the ICF Core Sets for MS. Other studies using Delphi surveys with physicians, (neuro)psychologists, nurses, occupational therapists, and speech and language therapists have been started in parallel. The content validity of the ICF Core Sets for MS is being explored further with statistical methods.
Finally, the physical therapists mentioned some issues that were difficult to link. For example, the term “spastic” was linked to b735 (muscle tone functions). One could argue that spastic could be linked to other categories, such as b750 (motor reflex functions) and b7801 (sensation of muscle spasm). Despite the importance of spasticity, there is as yet no single, agreed-upon definition of this phenomenon. However, a common construct underpinning all of the definitions is that spasticity is characterized by abnormal muscle activity. This abnormal muscle activity leads to an increase in muscle tone. Thus, the definition used in the literature supports the selection of the category b735 (muscle tone functions) as a link for “spastic.”98
Another issue was the linking of balance, joint and postural alignment, postural control, trunk stability, and core stability. The participants' statements could reflect the common interactions of posture, postural control, reactions, or stability as well as balance, proprioceptive function, or vestibular function, and several categories must be linked. An ICF category describing movement functions might be helpful for assessing and evaluating this issue.
Conclusion
Overall, the Comprehensive ICF Core Set for MS serves as a pool of categories to describe functioning in settings in which the comprehensive multidisciplinary description and assessment of functioning are necessary. The results of the present study support the content and face validity of the Comprehensive ICF Core Set for MS from the perspective of physical therapists experienced in the treatment of people with MS. The results identify the areas of functioning and health of people with MS that physical therapists believe should be assessed. The participating physical therapists also named issues that are important for the assessment of functioning in people with MS but that could not be linked to the ICF taxonomy (eg, walking and movement speed and compensatory movements). These potentially missing categories may be included in the ongoing process of updating the ICF.
The present study can be the starting point for further studies focusing on the identification of adequate outcome measures for assessing the ICF categories covered in the Comprehensive ICF Core Set for MS. Therefore, it is important to develop strategies for the implementation of the Comprehensive ICF Core Set for MS in clinical physical therapist practice. The findings of the present study, as well as the results of completed and ongoing validation studies, will further elucidate the validity of the Comprehensive ICF Core Set for MS from different perspectives. The findings of all of the validation studies will potentially result in a revised version of the Comprehensive ICF Core Set for MS.
Footnotes
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Dr Coenen and Dr Cieza provided concept/idea/research design. Ms Conrad, Dr Coenen, and Dr Cieza provided writing. Ms Conrad and Ms Schmalz provided data collection and data analysis. Dr Coenen and Dr Kesselring provided project management. Dr Kesselring provided fund procurement, facilities/equipment, and institutional liaisons. Ms Conrad provided participants. Ms Conrad, Dr Coenen, and Dr Kesselring provided consultation (including review of manuscript before submission).
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The authors thank all experts who participated in this study; these experts spent considerable time and effort and thus made the results possible: Kadriye Armutlu, Steve Ashford, Yvonne Bastmeijer-Blonk, Heidi Bedford, Susana Boglio, Diana Browne, Katrina Buchanan, Toni Chiara, Ingrid Claesson, Karol Connors, Susan Coote, Bridget Dickson, Ulrika Einarsson, Alison Elston, Ayla Fil, Anne Margrethe Fladmark, Maureen Forward, Neera Garga, Jane Gates, Kirsten Gollan, Daniela Görlitz, Leigh Hale, Amy Harrison, Antonia Henkel, Arja Henning, Martin Hennseler, Wendy Henry, Robert Johnston, Margareta Jonsson, Catherine Korte, Jham Kusum, Jane Lough, Julie Louie, Gaizka Loyola, Susie MacAllister, Ethirajulu Mahalakshmi, Emer Maher, Mandy McCulloch, Jennifer McKune, Linda Miller, Oscar Muncunill Morales, Ylva Nilsagard, Jaana Paltamaa, Jane Petty, Jane Priest, Pat Provance, Malin Rasten, Kerstin Rethemeier, Marc Rietberg, Rachele Rodoni Wetzel, Anders Romberg, Marianne Sandstrom, Karen Sayers, Corina Schuster, Michelle Shannon, Radhika Sharma, Merje Siiro, Christine Singleton, Stacey Sjoquist, Catherine Smith, Karen Smith, Jessie Snowdon, Regula Steinlin Egli, Fernanda Teixeira, Jenny Thain, Nanco van der Maas, Barbara van Marle, Tommy Vikman, Heike Wittenberg, Cheuk-wai Woo, and Sandra Zimmermann.
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This study was part of the project “Development of ICF Core Sets for MS” and was funded by the Gemeinnützige Hertie-Stiftung (1.01.1/06/008).
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The responsibility for the content of this publication lies with the ICF Research Branch.
- Received February 22, 2011.
- Accepted February 27, 2012.
- © 2012 American Physical Therapy Association
References
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