Identification of Intervention Categories for Physical Therapy, Based on theInternational Classification of Functioning, Disability and Health: A Delphi Exercise
Abstract
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Background and Purpose. Disability or limitations in human functioning are universal experiences that concern all people. Physical therapists aim to improve functioning and prevent disability. With the approval of the new International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally recognized framework and classification to be used in different health care situations by all health care professionals in multidisciplinary teams. The objective of this study was to identify ICF categories that describe the most relevant and common patient problems managed by physical therapists in acute, rehabilitation, and community health care situations taking into account 3 major groups of health conditions: musculoskeletal, neurological, and internal. Subjects.The subjects were physical therapists who were identified as possible participants by the heads of physical therapy departments who were members of the Swiss Association of Physical Therapy Department Heads or who were recruited from the membership of the Swiss Association of Physiotherapy. Methods. A consensus-building, 3-round, electronic-mail survey with 9 groups of physical therapists was conducted using the Delphi technique. Results. Two hundred sixty-three physical therapists participated in at least one round of the Delphi exercise. They had consensus levels of 80% or higher for categories in all ICF components (Body Functions, Body Structures, Activities and Participation, and Environmental Factors 1 and 2). Discussion and Conclusion. This study is a first step toward identifying a list of intervention categories relevant for physical therapy according to the ICF. The ICF, designed as a common language for multidisciplinary use, is also a very helpful framework for defining the core competence for the physical therapy profession.
Disability or limitations in human functioning are universal experiences that concern all people. Most human beings will experience limitation in functioning requiring health care services in acute or chronic conditions or with aging during their life spans. Thus, the provision of care targeted at the management of limitations in human functioning complements medical and surgical care throughout the service continuum from acute to community health care situations.1
Physical therapy is one of the health care professions involved in the management of limitations in functioning across acute, rehabilitation, and community health care situations.1 Physical therapists examine, evaluate, diagnose, and prognosticate limitations in functioning in close interaction with patients, families, and caregivers and taking into account the patients' goals, which determine the most appropriate interventions with the aim of optimizing functioning.2,3
Regardless of the health care situation, physical therapists provide services to patients and clients with problems related to the 3 major groups of health conditions: musculoskeletal, neurological, and internal.3–5 Physical therapists also collaborate with a variety of other professionals or are part of multidisciplinary and interdisciplinary teams,6–11 usually involving physicians, occupational therapists, nurses, social workers, vocational counselors, and clinical psychologists.12 For acute musculoskeletal and neuromuscular conditions, physical therapists are often the principal care providers within a multidisciplinary or interdisciplinary team. Physical therapists also provide services to patients who have been initially treated by other health care professionals and then referred to them.3
Although different professions work together with the common goal of managing limitations in functioning of patients, all of these different professions use different terminology and classifications for the description of patients' problems and, consequently, for the interventions goals. The lack of a common terminology and, accordingly, the lack of a common point of view may constitute a barrier to optimal team communication (eg, during team conferences).13 Multidisciplinary and interdisciplinary work could be facilitated by the use of a common frame of reference.14,15
In addition, the indication for physical therapy in many countries is still based on the diagnosis of health conditions typically classified according to the International Classification of Diseases (ICD).16 This classification, however, does not meet the needs of physical therapists, who require a more function-oriented framework as starting point for their work.14,17 Functioning, rather than the diagnosis, also reflects physical therapy resource utilization. Therefore, a payment system that relies on the diagnosis (as in many countries) does not reflect resource utilization in physical therapy. A more function-oriented framework or classification is necessary, not only from a clinical or practical point of view, but also from a health or economic point of view.
With the approval of the new International Classification of Functioning, Disability and Health (ICF),18 which replaced the International Classification of Impairments, Activities and Participation: A Manual of Dimension of Disablement and Functioning (ICIDH-2),19 we can now rely on a globally recognized framework and classification to be used in different health care situations by all health care professionals in multidisciplinary teams. The ICF contains lists of so-called ICF categories organized in 2 different parts: (1) Functioning and Disability and (2)Contextual Factors. Two different components belong to the functioning and disability part: (1) Body Functions and Structures and (2) Activities and Participation. The contextual factors part also is made up of 2 components: (1)Environmental Factors and (2) Personal Factors. Although personal factors have not yet been classified, they constitute a component of the ICF. The ICF categories represent the units of the ICF classification. Within the hierarchical coding system of the ICF classification, the ICF categories are designated by the letters “b” for body function, “s” for body structure, “d” for domain representing the component activity and participation, and “e” for environmental factor, followed by a numeric code starting with the chapter number (1 digit), followed by the second level (1 digits), and the third and fourth levels (1 digit each). Thus, within each chapter, there are individual 2-, 3-, or 4-level categories (Fig. 1). An example selected from the component Body Functions is presented below:
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b2 Sensory functions and pain (first level)
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b280 Sensation of pain (second level)
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b2801 Pain in body part (third level)
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b28013 Pain in back (fourth level)
Figure 1.
Structure of the International Classification of Functioning, Disability and Health (ICF).
The higher the level of specification, the more detailed is the information to which the ICF categories refer.
The ICF can be used as a common framework to identify patient problems typically managed by physical therapists and to describe them in a common and standardized language. Such a description can lead to the definition of widely accepted lists of ICF categories for physical therapy interventions. A possible approach to develop such lists is the Delphi technique.20
The objective of this study was to identify ICF categories that describe the most relevant and common patient problems managed by physical therapists in acute, rehabilitation, and community health care situations taking into account 3 diagnostic areas: musculoskeletal, neurological, and internal medicine.
- Background and Purpose. Disability or limitations in human functioning are universal experiences that concern all people. Physical therapists aim to improve functioning and prevent disability. With the approval of the new International Classification of Functioning, Disability and Health (ICF), we can now rely on a globally recognized framework and classification to be used in different health care situations by all health care professionals in multidisciplinary teams. The objective of this study was to identify ICF categories that describe the most relevant and common patient problems managed by physical therapists in acute, rehabilitation, and community health care situations taking into account 3 major groups of health conditions: musculoskeletal, neurological, and internal. Subjects.The subjects were physical therapists who were identified as possible participants by the heads of physical therapy departments who were members of the Swiss Association of Physical Therapy Department Heads or who were recruited from the membership of the Swiss Association of Physiotherapy. Methods. A consensus-building, 3-round, electronic-mail survey with 9 groups of physical therapists was conducted using the Delphi technique. Results. Two hundred sixty-three physical therapists participated in at least one round of the Delphi exercise. They had consensus levels of 80% or higher for categories in all ICF components (Body Functions, Body Structures, Activities and Participation, and Environmental Factors 1 and 2). Discussion and Conclusion. This study is a first step toward identifying a list of intervention categories relevant for physical therapy according to the ICF. The ICF, designed as a common language for multidisciplinary use, is also a very helpful framework for defining the core competence for the physical therapy profession.Disability or limitations in human functioning are universal experiences that concern all people. Most human beings will experience limitation in functioning requiring health care services in acute or chronic conditions or with aging during their life spans. Thus, the provision of care targeted at the management of limitations in human functioning complements medical and surgical care throughout the service continuum from acute to community health care situations.1Physical therapy is one of the health care professions involved in the management of limitations in functioning across acute, rehabilitation, and community health care situations.1 Physical therapists examine, evaluate, diagnose, and prognosticate limitations in functioning in close interaction with patients, families, and caregivers and taking into account the patients' goals, which determine the most appropriate interventions with the aim of optimizing functioning.2,3Regardless of the health care situation, physical therapists provide services to patients and clients with problems related to the 3 major groups of health conditions: musculoskeletal, neurological, and internal.3–5 Physical therapists also collaborate with a variety of other professionals or are part of multidisciplinary and interdisciplinary teams,6–11 usually involving physicians, occupational therapists, nurses, social workers, vocational counselors, and clinical psychologists.12 For acute musculoskeletal and neuromuscular conditions, physical therapists are often the principal care providers within a multidisciplinary or interdisciplinary team. Physical therapists also provide services to patients who have been initially treated by other health care professionals and then referred to them.3Although different professions work together with the common goal of managing limitations in functioning of patients, all of these different professions use different terminology and classifications for the description of patients' problems and, consequently, for the interventions goals. The lack of a common terminology and, accordingly, the lack of a common point of view may constitute a barrier to optimal team communication (eg, during team conferences).13 Multidisciplinary and interdisciplinary work could be facilitated by the use of a common frame of reference.14,15In addition, the indication for physical therapy in many countries is still based on the diagnosis of health conditions typically classified according to the International Classification of Diseases (ICD).16 This classification, however, does not meet the needs of physical therapists, who require a more function-oriented framework as starting point for their work.14,17 Functioning, rather than the diagnosis, also reflects physical therapy resource utilization. Therefore, a payment system that relies on the diagnosis (as in many countries) does not reflect resource utilization in physical therapy. A more function-oriented framework or classification is necessary, not only from a clinical or practical point of view, but also from a health or economic point of view.With the approval of the new International Classification of Functioning, Disability and Health (ICF),18 which replaced the International Classification of Impairments, Activities and Participation: A Manual of Dimension of Disablement and Functioning (ICIDH-2),19 we can now rely on a globally recognized framework and classification to be used in different health care situations by all health care professionals in multidisciplinary teams. The ICF contains lists of so-called ICF categories organized in 2 different parts: (1) Functioning and Disability and (2)Contextual Factors. Two different components belong to the functioning and disability part: (1) Body Functions and Structures and (2) Activities and Participation. The contextual factors part also is made up of 2 components: (1)Environmental Factors and (2) Personal Factors. Although personal factors have not yet been classified, they constitute a component of the ICF. The ICF categories represent the units of the ICF classification. Within the hierarchical coding system of the ICF classification, the ICF categories are designated by the letters “b” for body function, “s” for body structure, “d” for domain representing the component activity and participation, and “e” for environmental factor, followed by a numeric code starting with the chapter number (1 digit), followed by the second level (1 digits), and the third and fourth levels (1 digit each). Thus, within each chapter, there are individual 2-, 3-, or 4-level categories (Fig. 1). An example selected from the component Body Functions is presented below:
- b2 Sensory functions and pain (first level)
- b280 Sensation of pain (second level)
- b2801 Pain in body part (third level)
- b28013 Pain in back (fourth level)
Figure 1.Structure of the International Classification of Functioning, Disability and Health (ICF).The higher the level of specification, the more detailed is the information to which the ICF categories refer.The ICF can be used as a common framework to identify patient problems typically managed by physical therapists and to describe them in a common and standardized language. Such a description can lead to the definition of widely accepted lists of ICF categories for physical therapy interventions. A possible approach to develop such lists is the Delphi technique.20The objective of this study was to identify ICF categories that describe the most relevant and common patient problems managed by physical therapists in acute, rehabilitation, and community health care situations taking into account 3 diagnostic areas: musculoskeletal, neurological, and internal medicine.
Method
Study Design
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A consensus-building, 3-round, electronic-mail survey with 9 different groups of physical therapists was conducted using the Delphi technique. The Delphi technique is a structured communication process with 4 key characteristics: anonymity, iteration with controlled feedback, statistical group response, and informed input.21,22
The 9 groups corresponded to physical therapists working in acute, rehabilitation, and community health care situations and treating patients with problems related to 3 diagnostic areas: musculoskeletal, neurological, and internal medicine. In this article, the following designations (descriptive names) are used for the different groups: musculoskeletal/acute (MA), musculoskeletal/rehabilitation (MR), musculoskeletal/community health care situation (MC), neurological/acute (NA), neurological/rehabilitation (NR), neurological/community health care situation (NC), internal medicine/acute (IA), internal medicine/rehabilitation (IR), and internal medicine/community health care situation (IC).
- A consensus-building, 3-round, electronic-mail survey with 9 different groups of physical therapists was conducted using the Delphi technique. The Delphi technique is a structured communication process with 4 key characteristics: anonymity, iteration with controlled feedback, statistical group response, and informed input.21,22The 9 groups corresponded to physical therapists working in acute, rehabilitation, and community health care situations and treating patients with problems related to 3 diagnostic areas: musculoskeletal, neurological, and internal medicine. In this article, the following designations (descriptive names) are used for the different groups: musculoskeletal/acute (MA), musculoskeletal/rehabilitation (MR), musculoskeletal/community health care situation (MC), neurological/acute (NA), neurological/rehabilitation (NR), neurological/community health care situation (NC), internal medicine/acute (IA), internal medicine/rehabilitation (IR), and internal medicine/community health care situation (IC).
Participants
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Two different sources were used in the recruitment of physical therapists: (1) a letter was sent to all heads of physical therapy departments who were members of the Swiss Association of Physical Therapy Department Heads requesting them to provide the names of possible participants, and (2) a letter accompanying the official journal of the Swiss Association of Physiotherapy was sent to all the association's 6,200 members.
The study leader contacted interested physical therapists and requested from them information regarding the health care situation in which they worked, the kinds of patients that they were treating in their everyday work, and the years of practice with the different kinds of patients whom they were treating. Only the physical therapists who fulfilled the following inclusion criteria were invited to participate in the study: (1) having physical therapy as their main occupation, (2) working place in the German-, French-, or Italian-speaking part of Switzerland, (3) working with adults, (4) working in acute, rehabilitation, or community health care situations, and (5) having experience treating patients with problems related to the 3 major groups of health conditions (musculoskeletal, neurological, and internal) longer than 2 years.
After having confirmed their participation, the selected physical therapists were allocated to the 9 different groups by the study leader based on the reported practice patterns. Altogether, 263 physical therapists participated in at least one round of the Delphi exercise (208 from the German-speaking part of Switzerland, 43 from the French-speaking part of Switzerland, and 12 from the Italian-speaking part of Switzerland). Table 1 shows the numbers of physical therapists in each language group that responded in the different Delphi rounds, the median of the number of years of treating patients, and the corresponding response rates. Because a few physical therapists did not participate in all 3 Delphi rounds, the number of respondents in each round was slightly different.
- Two different sources were used in the recruitment of physical therapists: (1) a letter was sent to all heads of physical therapy departments who were members of the Swiss Association of Physical Therapy Department Heads requesting them to provide the names of possible participants, and (2) a letter accompanying the official journal of the Swiss Association of Physiotherapy was sent to all the association's 6,200 members.The study leader contacted interested physical therapists and requested from them information regarding the health care situation in which they worked, the kinds of patients that they were treating in their everyday work, and the years of practice with the different kinds of patients whom they were treating. Only the physical therapists who fulfilled the following inclusion criteria were invited to participate in the study: (1) having physical therapy as their main occupation, (2) working place in the German-, French-, or Italian-speaking part of Switzerland, (3) working with adults, (4) working in acute, rehabilitation, or community health care situations, and (5) having experience treating patients with problems related to the 3 major groups of health conditions (musculoskeletal, neurological, and internal) longer than 2 years.After having confirmed their participation, the selected physical therapists were allocated to the 9 different groups by the study leader based on the reported practice patterns. Altogether, 263 physical therapists participated in at least one round of the Delphi exercise (208 from the German-speaking part of Switzerland, 43 from the French-speaking part of Switzerland, and 12 from the Italian-speaking part of Switzerland). Table 1 shows the numbers of physical therapists in each language group that responded in the different Delphi rounds, the median of the number of years of treating patients, and the corresponding response rates. Because a few physical therapists did not participate in all 3 Delphi rounds, the number of respondents in each round was slightly different.
Data Collection
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The course of the Delphi exercise is displayed in Figure 2. In the first round of the Delphi exercise, open-ended, self-developed, group-specific questionnaires and information letters were sent by electronic mail to all recruited physical therapists. The questionnaires requested lists of body functions, body structures, activities and participation, and environmental factors influenced by physical therapy intervention. In addition, the questionnaires requested lists of relevant environmental factors that influence physical therapy intervention. In this article, the environmental factors influenced by physical therapy intervention will be referred to as environmental factors 1, and the environmental factors that influence physical therapy intervention will be referred to as environmental factors 2. The participants were not requested to use the ICF language to answer the first Delphi round.
Figure 2.
The course of the Delphi exercise. ICF=International Classification of Functioning, Disability and Health.
To illustrate the procedure, part of the questionnaire for Delphi round 1 for the IA group is shown in Figure 3. The information letter sent to the participants included background information; a description of the project's objective; the World Health Organization (WHO) definitions of body functions, body structures, activities and participation, and environmental factors; and instructions on how to fill in the questionnaires with a detailed time line. To clarify which kind of information was requested, an example was provided. The participants had 3 weeks to respond, and reminders were sent out approximately 2 days before the deadline. The participants did not know who else was participating in the Delphi exercise.
Figure 3.
Portion of the questionnaire used in Delphi round 1 for the internal medicine/acute group.
In the second round of the Delphi exercise, a self-developed, closed-ended questionnaire was sent together with corresponding instructions. Because the answers of the first round had been linked to the ICF, the questionnaire for Delphi round 2 included: (1) summary lists using the ICF language with all body functions, body structures, activities and participation, and environmental factors 1 and 2 that were named in the first round in the corresponding Delphi group, (2) information concerning whether the individual participant had named this ICF category in round 1, and (3) the percentage of all participants who had named this ICF category in the corresponding group. In addition, the participants were given a brief description of the hierarchical structure of the ICF and the Internet address of the WHO Web site in which they could find a browser with detailed descriptions of the 1,454 categories of the classification. To illustrate the procedure, part of the questionnaire for physical therapists in the IA group is shown in Figure 4. The participants were asked to consider whether a named ICF category is treated by physical therapists in patients with problems related to one of the diagnostic areas and within the corresponding situation. They were asked to take into account their own response and the answers of the group from the first round.
Figure 4.
Internal medicine/acute-specific portion of the questionnaire used in Delphi round 2. The first 2 columns include theInternational Classification of Functioning, Disability and Health (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 or she could find his or her code in one of the columns on the right side of the questionnaire. “Y” indicates that this category was named in the first round. The third column shows the percentage of participants who considered this ICF category as relevant or typical in round 1. In the fourth column, the participants were asked to respond “yes” or “no” whether they consider this category as relevant or typical for their treatment of patients with internal medicine conditions in the acute situation.
The participants of the first Delphi round, as well as a number of physical therapists whose addresses had not been available for the first round, were included in the second Delphi round. The participants had 2 weeks to respond, and reminders were sent out 2 days before the deadline.
In Delphi round 3, a questionnaire with corresponding instructions was sent to those participants who had responded in at least 1 of the first 2 rounds. The questionnaire for Delphi round 3 was similar to the questionnaire for 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 corresponding group. Again, the participants had 2 weeks to respond, and reminders were sent 2 days before the deadline.
The first round of the Delphi process was conducted in German, French, and Italian. Because the Italian version of the ICF was not available at the time the rounds 2 and 3 started, those rounds were conducted only in German and French. The therapists of the Italian part of Switzerland who could also speak either German or French participated in rounds 2 and 3. Four participants did not take part in the Delphi process after the first round because of language constraints.
- The course of the Delphi exercise is displayed in Figure 2. In the first round of the Delphi exercise, open-ended, self-developed, group-specific questionnaires and information letters were sent by electronic mail to all recruited physical therapists. The questionnaires requested lists of body functions, body structures, activities and participation, and environmental factors influenced by physical therapy intervention. In addition, the questionnaires requested lists of relevant environmental factors that influence physical therapy intervention. In this article, the environmental factors influenced by physical therapy intervention will be referred to as environmental factors 1, and the environmental factors that influence physical therapy intervention will be referred to as environmental factors 2. The participants were not requested to use the ICF language to answer the first Delphi round.Figure 2.The course of the Delphi exercise. ICF=International Classification of Functioning, Disability and Health.To illustrate the procedure, part of the questionnaire for Delphi round 1 for the IA group is shown in Figure 3. The information letter sent to the participants included background information; a description of the project's objective; the World Health Organization (WHO) definitions of body functions, body structures, activities and participation, and environmental factors; and instructions on how to fill in the questionnaires with a detailed time line. To clarify which kind of information was requested, an example was provided. The participants had 3 weeks to respond, and reminders were sent out approximately 2 days before the deadline. The participants did not know who else was participating in the Delphi exercise.Figure 3.Portion of the questionnaire used in Delphi round 1 for the internal medicine/acute group.In the second round of the Delphi exercise, a self-developed, closed-ended questionnaire was sent together with corresponding instructions. Because the answers of the first round had been linked to the ICF, the questionnaire for Delphi round 2 included: (1) summary lists using the ICF language with all body functions, body structures, activities and participation, and environmental factors 1 and 2 that were named in the first round in the corresponding Delphi group, (2) information concerning whether the individual participant had named this ICF category in round 1, and (3) the percentage of all participants who had named this ICF category in the corresponding group. In addition, the participants were given a brief description of the hierarchical structure of the ICF and the Internet address of the WHO Web site in which they could find a browser with detailed descriptions of the 1,454 categories of the classification. To illustrate the procedure, part of the questionnaire for physical therapists in the IA group is shown in Figure 4. The participants were asked to consider whether a named ICF category is treated by physical therapists in patients with problems related to one of the diagnostic areas and within the corresponding situation. They were asked to take into account their own response and the answers of the group from the first round.Figure 4.Internal medicine/acute-specific portion of the questionnaire used in Delphi round 2. The first 2 columns include theInternational Classification of Functioning, Disability and Health (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 or she could find his or her code in one of the columns on the right side of the questionnaire. “Y” indicates that this category was named in the first round. The third column shows the percentage of participants who considered this ICF category as relevant or typical in round 1. In the fourth column, the participants were asked to respond “yes” or “no” whether they consider this category as relevant or typical for their treatment of patients with internal medicine conditions in the acute situation.The participants of the first Delphi round, as well as a number of physical therapists whose addresses had not been available for the first round, were included in the second Delphi round. The participants had 2 weeks to respond, and reminders were sent out 2 days before the deadline.In Delphi round 3, a questionnaire with corresponding instructions was sent to those participants who had responded in at least 1 of the first 2 rounds. The questionnaire for Delphi round 3 was similar to the questionnaire for 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 corresponding group. Again, the participants had 2 weeks to respond, and reminders were sent 2 days before the deadline.The first round of the Delphi process was conducted in German, French, and Italian. Because the Italian version of the ICF was not available at the time the rounds 2 and 3 started, those rounds were conducted only in German and French. The therapists of the Italian part of Switzerland who could also speak either German or French participated in rounds 2 and 3. Four participants did not take part in the Delphi process after the first round because of language constraints.
Linking Process
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The participants' answers after the first Delphi round were linked to the ICF according to established linking rules.23 Therefore, a summary of the physical therapists' answers contained in the questionnaires used in Delphi rounds 2 and 3 was provided in the ICF language.
For the linking process, the Italian and French versions of the questionnaire used in Delphi round 1 were translated into German. Thus, the linking process was performed in German using the ICF version DIMDI (German Institute of Medical Documentation and Information) dated September 24, 2003.24
At the beginning of the linking process, 20% of the answers were linked separately by 2 trained health care professionals. Consensus was used to decide which ICF category should be linked to each answer. To resolve disagreements between the 2 health care professionals concerning the selected categories, a third person who was trained in the linking rules was consulted. In a discussion led by the third person, the 2 health care professionals who had linked the answers stated their pros and cons for linking the answer in question to a specific ICF category. Based on these statements, the third person made an informed decision. A physical therapist and a psychologist were always involved. Eighty percent of the answers were linked by only one health care professional. After entering the data, a physical therapist (MEF) checked the correctness of the linked categories. Having finished the linking process, the questionnaire used in Delphi round 2 was finalized in German. This final German version was then translated into French.
- The participants' answers after the first Delphi round were linked to the ICF according to established linking rules.23 Therefore, a summary of the physical therapists' answers contained in the questionnaires used in Delphi rounds 2 and 3 was provided in the ICF language.For the linking process, the Italian and French versions of the questionnaire used in Delphi round 1 were translated into German. Thus, the linking process was performed in German using the ICF version DIMDI (German Institute of Medical Documentation and Information) dated September 24, 2003.24At the beginning of the linking process, 20% of the answers were linked separately by 2 trained health care professionals. Consensus was used to decide which ICF category should be linked to each answer. To resolve disagreements between the 2 health care professionals concerning the selected categories, a third person who was trained in the linking rules was consulted. In a discussion led by the third person, the 2 health care professionals who had linked the answers stated their pros and cons for linking the answer in question to a specific ICF category. Based on these statements, the third person made an informed decision. A physical therapist and a psychologist were always involved. Eighty percent of the answers were linked by only one health care professional. After entering the data, a physical therapist (MEF) checked the correctness of the linked categories. Having finished the linking process, the questionnaire used in Delphi round 2 was finalized in German. This final German version was then translated into French.
Data Analysis
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Descriptive statistics were used to analyze the response rates. After each round of the Delphi exercise, the percentage of participants who considered an ICF category as treated by physical therapists was calculated separately for each group under consideration.
The ICF categories are presented on the second level of the classification. If an answer in the Delphi exercise was linked to a third- or fourth-level ICF category, the overlying second-level category was considered in this report. The ICF is organized in a hierarchy so that the more specific lower-level categories share the attributes of the less specific higher-level category.
The ICF categories with a frequency of 80% or higher are reported.25 This cutoff point was selected because a higher cutoff point (eg, 90%) would generate very few items, and a lower cutoff point (eg, 60%) would generate many items.
- Descriptive statistics were used to analyze the response rates. After each round of the Delphi exercise, the percentage of participants who considered an ICF category as treated by physical therapists was calculated separately for each group under consideration.The ICF categories are presented on the second level of the classification. If an answer in the Delphi exercise was linked to a third- or fourth-level ICF category, the overlying second-level category was considered in this report. The ICF is organized in a hierarchy so that the more specific lower-level categories share the attributes of the less specific higher-level category.The ICF categories with a frequency of 80% or higher are reported.25 This cutoff point was selected because a higher cutoff point (eg, 90%) would generate very few items, and a lower cutoff point (eg, 60%) would generate many items.
Results
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The whole 3-round, electronic-mail survey was performed in the first half of 2004 and completed within 12 weeks. Each Delphi round lasted approximately 1 month. The consensus process throughout the Delphi rounds is summarized in Table 2, where the numbers of categories supported by 80% or more of the participants of the different Delphi rounds considering all ICF components together are reported. In round 1 of the Delphi exercise, the participants named between 103 different ICF categories in the IR group and 201 categories in the NA group. Only a few ICF categories were named by 80% or more of the participants.
In round 2, there was 80% or higher agreement for relevant ICF categories in all 9 groups. The IC group had the lowest number of ICF categories with a consensus of 80% or higher (14 ICF categories), and the NC group had the highest number of ICF categories (74 ICF categories).
In round 3, the number of ICF categories with a consensus of at least 80% continued to increase. The NA group (89 ICF categories) and NC group (86 ICF categories) had the highest numbers of ICF categories with a consensus of at least 80%. The IC group (25 ICF categories) and the IR group (31 ICF categories) had the lowest numbers.
The Table 2 shows the ICF categories per ICF component that were supported by 80% or more of the participants at the third round. Tables 3⇓⇓⇓ through 7contain the ICF categories in the components Body Functions, Body Structures,Activities and Participation, and Environmental Factors 1 and 2 that were considered as treated by physical therapists by at least 80% of the participants in 1 of the 9 groups. The categories are presented in the ICF order of categorization.
Table 3.
International Classification of Functioning, Disability and Health(ICF) Categories in the ComponentBody Functions Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One Groupb
Table 4.
International Classification of Functioning, Disability and HealthCategories in the Component Body Structures Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One Groupa
Table 5.
International Classification of Functioning, Disability and HealthCategories in the ComponentActivities and Participation Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One Groupa
Table 6.
International Classification of Functioning, Disability and HealthCategories in the ComponentEnvironmental Factors 1 Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One Groupa
Table 7.
International Classification of Functioning, Disability and HealthCategories in the ComponentEnvironmental Factors 2 Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One Groupa
In the component Body Functions, 46 different ICF categories reached a consensus of 80% or higher in at least one of the groups. Only 4 categories reached a consensus of 80% or higher throughout all 9 groups. These were category b280–sensation of pain and 3 other categories in chapter b7–neuromusculoskeletal and movement-related functions (ie, b710–mobility of joint functions, b730–muscle power functions, and b740–muscle endurance functions). Another 7 categories in chapters b1–mental functions, b2–sensory functions and pain, b4–functions of the cardiovascular, haematological, immunological, and respiratory systems, and b7–neuromusculoskeletal and movement-related functions reached a consensus of 80% or higher in at least 7 groups.
Categories in chapters b2–sensory functions and pain, b5–functions of the digestive, metabolic and endocrine systems, and b7–neuromusculoskeletal and movement-related functions reached a consensus of 80% or higher specifically for the 3 neurological groups. Twenty-four categories in chapters b1–mental functions, b2–sensory functions and pain, b4–functions of the cardiovascular, haematological, immunological, and respiratory systems, b5–functions of the digestive, metabolic, and endocrine systems, and b7–neuromusculoskeletal and movement-related functions were considered as treated by physical therapists by 100% of the participants in at least one group.
In the component Body Structures, 18 different ICF categories reached a consensus of 80% or higher in at least 1 of the 9 groups. Only one body structure (s760–structure of trunk) reached a consensus of 80% or higher in 7 or more groups. Nine categories in chapters s1–structures of the nervous system, s4–structures of the cardiovascular, immunological, and respiratory systems, and s7–structures related to movementwere considered as treated by physical therapists by 100% of the participants in at least one group.
In the component Activities and Participation, 38 different ICF categories reached a consensus of 80% or higher in at least one of the health conditions. The ICF category d450–walking reached a consensus of 80% or higher in all 9 groups. Four categories (ie, d230–carrying out daily routine, d410–changing basic body position, d415–maintaining a body position, and d430–lifting and carrying objects) reached a consensus of at least 80% in 7 or more groups. Categories from chapterd1–learning and applying knowledge were mainly chosen by the 3 neurology groups. The ICF categories d440–fine hand use, d510–washing oneself, d530–toileting, d550–eating, and d560–drinking also were specific to the 3 neurology groups. The ICF category d845–acquiring, keeping, and terminating a job was specific to all 3 musculoskeletal groups and the IC group.
In the component Environmental Factors 1, 11 different ICF categories reached a consensus of 80% or higher in at least one group. However, only the ICF categoriese310–immediate family and e355–health professionals reached a consensus of 80% or higher in all 9 groups.
In the component Environmental Factors 2, 19 different ICF categories reached a consensus of 80% or higher in at least one group. The ICF categories e110–products or substances for personal consumption, e310–immediate family, e355–health professionals, and e580–health services, systems, and policies attained a consensus of 80% or higher in all 9 groups.
- The whole 3-round, electronic-mail survey was performed in the first half of 2004 and completed within 12 weeks. Each Delphi round lasted approximately 1 month. The consensus process throughout the Delphi rounds is summarized in Table 2, where the numbers of categories supported by 80% or more of the participants of the different Delphi rounds considering all ICF components together are reported. In round 1 of the Delphi exercise, the participants named between 103 different ICF categories in the IR group and 201 categories in the NA group. Only a few ICF categories were named by 80% or more of the participants.In round 2, there was 80% or higher agreement for relevant ICF categories in all 9 groups. The IC group had the lowest number of ICF categories with a consensus of 80% or higher (14 ICF categories), and the NC group had the highest number of ICF categories (74 ICF categories).In round 3, the number of ICF categories with a consensus of at least 80% continued to increase. The NA group (89 ICF categories) and NC group (86 ICF categories) had the highest numbers of ICF categories with a consensus of at least 80%. The IC group (25 ICF categories) and the IR group (31 ICF categories) had the lowest numbers.The Table 2 shows the ICF categories per ICF component that were supported by 80% or more of the participants at the third round. Tables 3⇓⇓⇓ through 7contain the ICF categories in the components Body Functions, Body Structures,Activities and Participation, and Environmental Factors 1 and 2 that were considered as treated by physical therapists by at least 80% of the participants in 1 of the 9 groups. The categories are presented in the ICF order of categorization.Table 3.International Classification of Functioning, Disability and Health(ICF) Categories in the ComponentBody Functions Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One GroupbTable 4.International Classification of Functioning, Disability and HealthCategories in the Component Body Structures Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One GroupaTable 5.International Classification of Functioning, Disability and HealthCategories in the ComponentActivities and Participation Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One GroupaTable 6.International Classification of Functioning, Disability and HealthCategories in the ComponentEnvironmental Factors 1 Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One GroupaTable 7.International Classification of Functioning, Disability and HealthCategories in the ComponentEnvironmental Factors 2 Considered as Relevant or Typical to Be Influenced by Physical Therapy by ≥80% of the Participants in at Least One GroupaIn the component Body Functions, 46 different ICF categories reached a consensus of 80% or higher in at least one of the groups. Only 4 categories reached a consensus of 80% or higher throughout all 9 groups. These were category b280–sensation of pain and 3 other categories in chapter b7–neuromusculoskeletal and movement-related functions (ie, b710–mobility of joint functions, b730–muscle power functions, and b740–muscle endurance functions). Another 7 categories in chapters b1–mental functions, b2–sensory functions and pain, b4–functions of the cardiovascular, haematological, immunological, and respiratory systems, and b7–neuromusculoskeletal and movement-related functions reached a consensus of 80% or higher in at least 7 groups.Categories in chapters b2–sensory functions and pain, b5–functions of the digestive, metabolic and endocrine systems, and b7–neuromusculoskeletal and movement-related functions reached a consensus of 80% or higher specifically for the 3 neurological groups. Twenty-four categories in chapters b1–mental functions, b2–sensory functions and pain, b4–functions of the cardiovascular, haematological, immunological, and respiratory systems, b5–functions of the digestive, metabolic, and endocrine systems, and b7–neuromusculoskeletal and movement-related functions were considered as treated by physical therapists by 100% of the participants in at least one group.In the component Body Structures, 18 different ICF categories reached a consensus of 80% or higher in at least 1 of the 9 groups. Only one body structure (s760–structure of trunk) reached a consensus of 80% or higher in 7 or more groups. Nine categories in chapters s1–structures of the nervous system, s4–structures of the cardiovascular, immunological, and respiratory systems, and s7–structures related to movementwere considered as treated by physical therapists by 100% of the participants in at least one group.In the component Activities and Participation, 38 different ICF categories reached a consensus of 80% or higher in at least one of the health conditions. The ICF category d450–walking reached a consensus of 80% or higher in all 9 groups. Four categories (ie, d230–carrying out daily routine, d410–changing basic body position, d415–maintaining a body position, and d430–lifting and carrying objects) reached a consensus of at least 80% in 7 or more groups. Categories from chapterd1–learning and applying knowledge were mainly chosen by the 3 neurology groups. The ICF categories d440–fine hand use, d510–washing oneself, d530–toileting, d550–eating, and d560–drinking also were specific to the 3 neurology groups. The ICF category d845–acquiring, keeping, and terminating a job was specific to all 3 musculoskeletal groups and the IC group.In the component Environmental Factors 1, 11 different ICF categories reached a consensus of 80% or higher in at least one group. However, only the ICF categoriese310–immediate family and e355–health professionals reached a consensus of 80% or higher in all 9 groups.In the component Environmental Factors 2, 19 different ICF categories reached a consensus of 80% or higher in at least one group. The ICF categories e110–products or substances for personal consumption, e310–immediate family, e355–health professionals, and e580–health services, systems, and policies attained a consensus of 80% or higher in all 9 groups.
Discussion
-
This Delphi exercise showed a high consensus among physical therapists concerning the most relevant and common patient problems managed by physical therapists in musculoskeletal, neurological, and internal medical specialties in acute, rehabilitation, and community health care settings. The results of this study tell us which areas of functioning and disability physical therapists target with their interventions. In general, these results are in line with our clinical experience and with the literature.
All 9 groups had consensus levels of 80% or higher for categories in all ICF components (Body Functions, Body Structures, Activities and Participation, andEnvironmental Factors I and II). The largest lists throughout the 9 groups were those of the components Body Functions and Activities and Participation. Within these 2 components, the highest consensus throughout most groups was reached in categories related to movement. These results correspond with earlier findings26,27 and support the notion that body functions and activities and their relationship are the main areas of competence among physical therapists. Functions of the musculoskeletal system and activities dependent on it represent, in our experience, the most frequent intervention goals of physical therapists, regardless of the clinical setting in which they work.
In addition to some categories of chapter b7–neuromusculoskeletal and movement-related functions, the category b280–sensation of pain reached a consensus of 80% or higher throughout all 9 groups within the component Body Functions. This finding clearly reflects that pain and its consequences are a central focus of physical therapy intervention.28–32
In the component Environmental Factors 1, categories reflecting drugs, devices, family, education, and teamwork with other health care professionals reached a high consensus in all 9 groups. This finding reflects the broad spectrum of environmental factors influenced by physical therapists. Findings from basic neurosciences emphasize the fact that the environment plays a major role in the recovery of function.33
The lack of literature studying the aspects of patient's environments treated by physical therapists may reflect the fact that most clinical studies and surveys focus on interventions and techniques aimed at improving the physical impairment, forgetting that the spectrum of areas targeted by physical therapists is much broader. Moreover, to our knowledge, this is the first study in which physical therapists have explicitly been questioned on the environmental factors they address in their treatment.
The categories considered relevant differed largely among the groups. The lists of the 3 neurological groups covered topics related to the component Body Functionsand included the largest number of categories related to chapters b1–mental functions, b2–sensory functions,34,35 and b5–function of the digestive, metabolic, and endocrine systems.36 In the component Activities and Participation, the neurology-specific categories were in chapter d1–learning and applying knowledgeand especially in chapter d5–self-care. Those findings corresponded with the extensive needs identified in patients with stroke,37,38 multiple sclerosis,39 and Parkinson disease.40
The 3 musculoskeletal groups shared most of their categories with a consensus of 80% or higher with the neurological groups. One exception seemed to be the category d845–acquiring, keeping, and terminating a job from the componentActivities and Participation. This category reflected the reality of physical therapists working in the musculoskeletal area, where keeping a job or return to work is a major goal, or represents an important prognostic factor for recovery.41,42
The 3 internal medicine condition groups had the shortest list of categories with a consensus of 80% or higher. A few categories from chapter b4–functions of the cardiovascular, haematological, immunological, and respiratory systems from the component Body Functions are specific to the internal medicine area (eg, b415–blood vessel functions). The categories b420–blood pressure functions and b450–additional respiratory functions were specific for the groups IA and IR. The category b450–additional respiratory functions, which is defined as “additional functions related to breathing, such as coughing, sneezing, and yawning,” reflects the special needs of a large percentage of patients with internal medicine conditions.43,44
The finding that there are both categories common to all 3 diagnostic areas and categories specific to musculoskeletal, neurological, and internal medicine areas supports the concept of developing a core list of relevant categories for physical therapists complemented by lists of categories specific for musculoskeletal, neurological, and internal medicine conditions. However, no further decisions regarding the ICF categories to be included in a list covering all areas and diagnosis will be made based on the results presented in this article. Further studies investigating the content validity of the results of this Delphi exercise must first be carried out.
Interestingly, no categories could be identified as characteristic for any of the treatment situations. This may be due to the lack of situation-specific goal setting or due to the wide focus of physical therapists, who try to consider all possible interventions in the continuum from acute to community health care situations.45,46
- This Delphi exercise showed a high consensus among physical therapists concerning the most relevant and common patient problems managed by physical therapists in musculoskeletal, neurological, and internal medical specialties in acute, rehabilitation, and community health care settings. The results of this study tell us which areas of functioning and disability physical therapists target with their interventions. In general, these results are in line with our clinical experience and with the literature.All 9 groups had consensus levels of 80% or higher for categories in all ICF components (Body Functions, Body Structures, Activities and Participation, andEnvironmental Factors I and II). The largest lists throughout the 9 groups were those of the components Body Functions and Activities and Participation. Within these 2 components, the highest consensus throughout most groups was reached in categories related to movement. These results correspond with earlier findings26,27 and support the notion that body functions and activities and their relationship are the main areas of competence among physical therapists. Functions of the musculoskeletal system and activities dependent on it represent, in our experience, the most frequent intervention goals of physical therapists, regardless of the clinical setting in which they work.In addition to some categories of chapter b7–neuromusculoskeletal and movement-related functions, the category b280–sensation of pain reached a consensus of 80% or higher throughout all 9 groups within the component Body Functions. This finding clearly reflects that pain and its consequences are a central focus of physical therapy intervention.28–32In the component Environmental Factors 1, categories reflecting drugs, devices, family, education, and teamwork with other health care professionals reached a high consensus in all 9 groups. This finding reflects the broad spectrum of environmental factors influenced by physical therapists. Findings from basic neurosciences emphasize the fact that the environment plays a major role in the recovery of function.33The lack of literature studying the aspects of patient's environments treated by physical therapists may reflect the fact that most clinical studies and surveys focus on interventions and techniques aimed at improving the physical impairment, forgetting that the spectrum of areas targeted by physical therapists is much broader. Moreover, to our knowledge, this is the first study in which physical therapists have explicitly been questioned on the environmental factors they address in their treatment.The categories considered relevant differed largely among the groups. The lists of the 3 neurological groups covered topics related to the component Body Functionsand included the largest number of categories related to chapters b1–mental functions, b2–sensory functions,34,35 and b5–function of the digestive, metabolic, and endocrine systems.36 In the component Activities and Participation, the neurology-specific categories were in chapter d1–learning and applying knowledgeand especially in chapter d5–self-care. Those findings corresponded with the extensive needs identified in patients with stroke,37,38 multiple sclerosis,39 and Parkinson disease.40The 3 musculoskeletal groups shared most of their categories with a consensus of 80% or higher with the neurological groups. One exception seemed to be the category d845–acquiring, keeping, and terminating a job from the componentActivities and Participation. This category reflected the reality of physical therapists working in the musculoskeletal area, where keeping a job or return to work is a major goal, or represents an important prognostic factor for recovery.41,42The 3 internal medicine condition groups had the shortest list of categories with a consensus of 80% or higher. A few categories from chapter b4–functions of the cardiovascular, haematological, immunological, and respiratory systems from the component Body Functions are specific to the internal medicine area (eg, b415–blood vessel functions). The categories b420–blood pressure functions and b450–additional respiratory functions were specific for the groups IA and IR. The category b450–additional respiratory functions, which is defined as “additional functions related to breathing, such as coughing, sneezing, and yawning,” reflects the special needs of a large percentage of patients with internal medicine conditions.43,44The finding that there are both categories common to all 3 diagnostic areas and categories specific to musculoskeletal, neurological, and internal medicine areas supports the concept of developing a core list of relevant categories for physical therapists complemented by lists of categories specific for musculoskeletal, neurological, and internal medicine conditions. However, no further decisions regarding the ICF categories to be included in a list covering all areas and diagnosis will be made based on the results presented in this article. Further studies investigating the content validity of the results of this Delphi exercise must first be carried out.Interestingly, no categories could be identified as characteristic for any of the treatment situations. This may be due to the lack of situation-specific goal setting or due to the wide focus of physical therapists, who try to consider all possible interventions in the continuum from acute to community health care situations.45,46
Practical Implications
-
Although the results of this study are preliminary and have to be validated by additional studies, the use of the generated lists can be illustrated by an example. It must be kept in mind that the process will be schematically presented and simplified in this article. Let us imagine a 45-year-old patient with rheumatoid arthritis who has been referred to a rehabilitation program due to worsening function of hands, fingers, and wrist joints and increasing problems in the feet, shoulder, and knee. The increased pain interferes with different life areas, such as self-care, work, sexual life, and recreational activities. The list of ICF categories referring to musculoskeletal conditions and the rehabilitation setting can be used as a basis for documentation of the functional diagnosis within the 5 elements differentiated in patient management (examination, evaluation, diagnosis, prognosis, and intervention) (Fig. 5). The information gathered from the examination and evaluation can be integrated and documented using the ICF lists proposed in this article. Although in the example presented here only problem versus no problem is documented for each of the ICF categories, the ICF qualifiers also can be used18 to indicate the extent of the problem. A profile of functioning indicating the patient's problems evolves, which enables the physical therapist to tailor his or her interventions to the individual patient. The same profile can be used for the re-examination to evaluate the process of the interventions.
Figure 5.
Simplified documentation of the functional diagnosis within the 5 elements differentiated in the patient management, using the list for musculoskeletal/rehabilitation. ICF=International Classification of Functioning, Disability and Health.
It is important to emphasize that these lists also can be integrated into a “Rehabilitation Problem-Solving Form,” which allows all the members of a multidisciplinary team to work together to analyze patients' problems and determine specific goals.14 The utilization of a universal and standardized language and process in the determination of intervention targets will undoubtedly stimulate multidisciplinary practice and research with the common goal of optimizing participation from the perspective of both the patient and society.47
It is envisioned that the final resulting lists will be practical tools to be used by physical therapists to document their intervention targets and to plan their intervention process in a standardized and universal way. Edwards et al,48 in a study on clinical reasoning strategies in physical therapy, proposed a model that fit the WHO model of functioning and disability, which is the basis of the ICF, and recommended that health care practitioners collect information based on the ICF in their everyday clinical practice. The envisaged practical lists of intervention categories can definitely contribute to this recommendation.
Because the ICF now contains the neutral terms “body functions and structures” and “activities and participation” as compared with the prior “negative” terms “impairment,” “disability,” and “handicap,” it very much conforms to the positive view and the resource-oriented perspective of physical therapists. The ICF is also a language that can be understood by patients. It, therefore, comes as no surprise that patient organizations and their advocates also are recognizing the potential of the ICF to generally strengthen the patient perspective in medicine and health systems.49 Therefore, the documentation of intervention categories based on the ICF may respond to the needs of physical therapists and improve communication with patients. It is easier for patients to understand their functioning and health, treatment goals, and an intervention plan based on a language that they and their proxies (eg, family members, friends, and neighbors) can understand.
- Although the results of this study are preliminary and have to be validated by additional studies, the use of the generated lists can be illustrated by an example. It must be kept in mind that the process will be schematically presented and simplified in this article. Let us imagine a 45-year-old patient with rheumatoid arthritis who has been referred to a rehabilitation program due to worsening function of hands, fingers, and wrist joints and increasing problems in the feet, shoulder, and knee. The increased pain interferes with different life areas, such as self-care, work, sexual life, and recreational activities. The list of ICF categories referring to musculoskeletal conditions and the rehabilitation setting can be used as a basis for documentation of the functional diagnosis within the 5 elements differentiated in patient management (examination, evaluation, diagnosis, prognosis, and intervention) (Fig. 5). The information gathered from the examination and evaluation can be integrated and documented using the ICF lists proposed in this article. Although in the example presented here only problem versus no problem is documented for each of the ICF categories, the ICF qualifiers also can be used18 to indicate the extent of the problem. A profile of functioning indicating the patient's problems evolves, which enables the physical therapist to tailor his or her interventions to the individual patient. The same profile can be used for the re-examination to evaluate the process of the interventions.Figure 5.Simplified documentation of the functional diagnosis within the 5 elements differentiated in the patient management, using the list for musculoskeletal/rehabilitation. ICF=International Classification of Functioning, Disability and Health.It is important to emphasize that these lists also can be integrated into a “Rehabilitation Problem-Solving Form,” which allows all the members of a multidisciplinary team to work together to analyze patients' problems and determine specific goals.14 The utilization of a universal and standardized language and process in the determination of intervention targets will undoubtedly stimulate multidisciplinary practice and research with the common goal of optimizing participation from the perspective of both the patient and society.47It is envisioned that the final resulting lists will be practical tools to be used by physical therapists to document their intervention targets and to plan their intervention process in a standardized and universal way. Edwards et al,48 in a study on clinical reasoning strategies in physical therapy, proposed a model that fit the WHO model of functioning and disability, which is the basis of the ICF, and recommended that health care practitioners collect information based on the ICF in their everyday clinical practice. The envisaged practical lists of intervention categories can definitely contribute to this recommendation.Because the ICF now contains the neutral terms “body functions and structures” and “activities and participation” as compared with the prior “negative” terms “impairment,” “disability,” and “handicap,” it very much conforms to the positive view and the resource-oriented perspective of physical therapists. The ICF is also a language that can be understood by patients. It, therefore, comes as no surprise that patient organizations and their advocates also are recognizing the potential of the ICF to generally strengthen the patient perspective in medicine and health systems.49 Therefore, the documentation of intervention categories based on the ICF may respond to the needs of physical therapists and improve communication with patients. It is easier for patients to understand their functioning and health, treatment goals, and an intervention plan based on a language that they and their proxies (eg, family members, friends, and neighbors) can understand.
Limitations
-
A major limitation of the study is the lack of personal factors in the proposed tentative lists of intervention categories for physical therapy. Personal factors play an important role in identifying the best strategy to empower the patient to actively participate in his or her treatment and to develop an optimal treatment plan.50–52 Moreover, the interaction of personal factors with the intervention and with environmental factors is extremely important for clinical practice, because they can dramatically influence the outcome of physical therapy interventions. As long as the ICF does not include personal factors, they cannot be recorded in a standardized way.
The importance of the personal factors was emphasized in this study by the fact that the participants also named “personal factors,” which we did not explicitly request in the first Delphi round. We summarized these named personal factors in a list containing 18 items. The following 8 items were considered relevant with a consensus of 80% or higher throughout all groups: personal fitness, comorbidities, psychological status, lifestyle, coping style, personal goals and expectances, patient's individual attitude toward physical therapy intervention, and the social network. This list of personal factors has to be considered tentative because it was not developed systematically. However, it clearly indicates the need for a classification of personal factors.
The Delphi technique seems to be an appropriate method to attain the objective of this study. In contrast to the mean attrition rates of 50% or higher from round to round reported in the literature,53,54 we achieved in our study response rates ranging from 73% to 90% in round 3. However, different issues need to be mentioned regarding the response rates. In the second Delphi round, the same participants of the first Delphi round as well as a number of participants whose addresses had not been available for the first round were included. In the third round, those participants who had responded in at least 1 of the first 2 rounds were included. This procedure explains the variation in response rates across the Delphi rounds and leaves the question open whether the inclusion of participants in the second and third rounds who had not answered the first or second round, respectively, influenced the results of this investigation.
Regarding the external validity of this study, there are also some limitations that require special attention. The first limitation refers to the 80% cutoff point, which was selected for practical reasons. It still remains, to some extent, arbitrary and therefore can be criticized.
Although we were successful in recruiting a group of 263 physical therapists from all 3 different language-speaking regions of Switzerland (80% from the German-speaking part, 17% from the French-speaking part, and 3% from the Italian-speaking part) with a distribution that was equivalent to the real distribution of physical therapists in those 3 regions, this distribution was not maintained in the 9 different groups.
Although much care was taken in the selection of physical therapists and a wide range of institutions and private practices were included, not all special therapeutic fields were covered. We had, for example, no participants from a spinal cord center in the neurological group in the rehabilitation phase. A relatively high percentage of physical therapists working in teaching or university hospitals were present in the internal medicine group in the acute phase. Therefore, 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 overestimated.
In addition, the sample size of some of the 9 different groups was smaller than 15. This was the case in the IC group and the IR group with 12 participants in the second Delphi round and 14 in the third Delphi round. The results concerning these groups have to be viewed with caution and need to be validated in the future. The composition of the different groups, as well as the sample size, has to be taken into account when generalizing the results to the whole population of Swiss physical therapists.
- A major limitation of the study is the lack of personal factors in the proposed tentative lists of intervention categories for physical therapy. Personal factors play an important role in identifying the best strategy to empower the patient to actively participate in his or her treatment and to develop an optimal treatment plan.50–52 Moreover, the interaction of personal factors with the intervention and with environmental factors is extremely important for clinical practice, because they can dramatically influence the outcome of physical therapy interventions. As long as the ICF does not include personal factors, they cannot be recorded in a standardized way.The importance of the personal factors was emphasized in this study by the fact that the participants also named “personal factors,” which we did not explicitly request in the first Delphi round. We summarized these named personal factors in a list containing 18 items. The following 8 items were considered relevant with a consensus of 80% or higher throughout all groups: personal fitness, comorbidities, psychological status, lifestyle, coping style, personal goals and expectances, patient's individual attitude toward physical therapy intervention, and the social network. This list of personal factors has to be considered tentative because it was not developed systematically. However, it clearly indicates the need for a classification of personal factors.The Delphi technique seems to be an appropriate method to attain the objective of this study. In contrast to the mean attrition rates of 50% or higher from round to round reported in the literature,53,54 we achieved in our study response rates ranging from 73% to 90% in round 3. However, different issues need to be mentioned regarding the response rates. In the second Delphi round, the same participants of the first Delphi round as well as a number of participants whose addresses had not been available for the first round were included. In the third round, those participants who had responded in at least 1 of the first 2 rounds were included. This procedure explains the variation in response rates across the Delphi rounds and leaves the question open whether the inclusion of participants in the second and third rounds who had not answered the first or second round, respectively, influenced the results of this investigation.Regarding the external validity of this study, there are also some limitations that require special attention. The first limitation refers to the 80% cutoff point, which was selected for practical reasons. It still remains, to some extent, arbitrary and therefore can be criticized.Although we were successful in recruiting a group of 263 physical therapists from all 3 different language-speaking regions of Switzerland (80% from the German-speaking part, 17% from the French-speaking part, and 3% from the Italian-speaking part) with a distribution that was equivalent to the real distribution of physical therapists in those 3 regions, this distribution was not maintained in the 9 different groups.Although much care was taken in the selection of physical therapists and a wide range of institutions and private practices were included, not all special therapeutic fields were covered. We had, for example, no participants from a spinal cord center in the neurological group in the rehabilitation phase. A relatively high percentage of physical therapists working in teaching or university hospitals were present in the internal medicine group in the acute phase. Therefore, 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 overestimated.In addition, the sample size of some of the 9 different groups was smaller than 15. This was the case in the IC group and the IR group with 12 participants in the second Delphi round and 14 in the third Delphi round. The results concerning these groups have to be viewed with caution and need to be validated in the future. The composition of the different groups, as well as the sample size, has to be taken into account when generalizing the results to the whole population of Swiss physical therapists.
Future Research Directions
-
Within this context, it is important to emphasize that the results of this investigation represent the perspective of physical therapists working in Switzerland and are not suitable to be generalized to other countries and world regions. In addition, the results of any consensus process may differ with different groups of participants. Therefore, further studies in different countries and with different participants are needed to come up with a universal proposal of relevant intervention categories for physical therapists based on the ICF.
Furthermore, the process of developing physical therapy–specific lists of ICF categories to describe the most relevant and common patient problems managed by physical therapists in Switzerland will be iterative and involving many different steps. A consensus conference involving physical therapists from Switzerland working in acute, rehabilitation, and community health care situations has been conducted on the basis of the results of the Delphi exercise presented here.
A Delphi exercise was performed before the consensus conference due to the comprehensiveness of the classification with its 1,454 categories. A preselection of categories based on the Delphi exercise presented here seemed to be the most appropriate procedure to enable a brief and structured decision-making and consensus process.
After the consensus conference, the content validity of the resulting lists is being further studied in different health care situations. The content validity is being analyzed by examining the frequency with which the ICF categories in the first version of the ICF intervention categories for physical therapy represent the patient problems that are documented in the category “functional diagnosis” of the physical therapy management process. It is important to emphasize that this is a matter of content validity and not of validity and reliability in a psychometric sense.
Education and teaching are fundamental activities in the clinical practice of physical therapists.49 The question that remains unanswered, but can be validated within the scope of future studies, is whether a structured process during the selection and documentation of intervention targets may help young physical therapy practitioners in the management of their functioning-oriented interventions.
- Within this context, it is important to emphasize that the results of this investigation represent the perspective of physical therapists working in Switzerland and are not suitable to be generalized to other countries and world regions. In addition, the results of any consensus process may differ with different groups of participants. Therefore, further studies in different countries and with different participants are needed to come up with a universal proposal of relevant intervention categories for physical therapists based on the ICF.Furthermore, the process of developing physical therapy–specific lists of ICF categories to describe the most relevant and common patient problems managed by physical therapists in Switzerland will be iterative and involving many different steps. A consensus conference involving physical therapists from Switzerland working in acute, rehabilitation, and community health care situations has been conducted on the basis of the results of the Delphi exercise presented here.A Delphi exercise was performed before the consensus conference due to the comprehensiveness of the classification with its 1,454 categories. A preselection of categories based on the Delphi exercise presented here seemed to be the most appropriate procedure to enable a brief and structured decision-making and consensus process.After the consensus conference, the content validity of the resulting lists is being further studied in different health care situations. The content validity is being analyzed by examining the frequency with which the ICF categories in the first version of the ICF intervention categories for physical therapy represent the patient problems that are documented in the category “functional diagnosis” of the physical therapy management process. It is important to emphasize that this is a matter of content validity and not of validity and reliability in a psychometric sense.Education and teaching are fundamental activities in the clinical practice of physical therapists.49 The question that remains unanswered, but can be validated within the scope of future studies, is whether a structured process during the selection and documentation of intervention targets may help young physical therapy practitioners in the management of their functioning-oriented interventions.
Conclusion
-
This study is a first step toward identifying a list of intervention categories relevant for physical therapy treatment according to the ICF. The Delphi exercise proved to be a valuable and an effective approach to generate an initial list of intervention categories. Further studies to test the content validity and generalizability of our results are in progress.
- This study is a first step toward identifying a list of intervention categories relevant for physical therapy treatment according to the ICF. The Delphi exercise proved to be a valuable and an effective approach to generate an initial list of intervention categories. Further studies to test the content validity and generalizability of our results are in progress.
Footnotes
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-
Ms Finger, Dr Cieza, Dr Stucki, and Ms Huber provided concept/idea/research design. Ms Finger, Dr Cieza, and Dr Stucki provided writing. Ms Finger provided data collection, and Ms Finger and Mr Stoll provided data analysis. Dr Stucki provided facilities/equipment. Dr Stucki and Ms Huber provided institutional liaisons and consultation (including review of manuscript before submission). The authors acknowledge the cooperation, sacrifice of time, and reflective responses to the demanding questionnaires from all participants in the Delphi exercise.
-
An abstract of this research was presented at the Annual Swiss National Congress of Rheumatology; September 29–30, 2005; Davos, Switzerland.
- Received April 24, 2005.
- Accepted April 27, 2006.
- Physical Therapy
- Ms Finger, Dr Cieza, Dr Stucki, and Ms Huber provided concept/idea/research design. Ms Finger, Dr Cieza, and Dr Stucki provided writing. Ms Finger provided data collection, and Ms Finger and Mr Stoll provided data analysis. Dr Stucki provided facilities/equipment. Dr Stucki and Ms Huber provided institutional liaisons and consultation (including review of manuscript before submission). The authors acknowledge the cooperation, sacrifice of time, and reflective responses to the demanding questionnaires from all participants in the Delphi exercise.
- An abstract of this research was presented at the Annual Swiss National Congress of Rheumatology; September 29–30, 2005; Davos, Switzerland.
- Received April 24, 2005.
- Accepted April 27, 2006.
- Physical Therapy
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