Identification of intervention categories for physical therapy, based on the International Classification of Functioning, Disability and Health: a Delphi exercise.

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:

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 OMITTED]

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.

Method

Study Design

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).

Participants

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

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 OMITTED]

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.

Please list in the      Please list in the      Please list in the
following cells body    following cells body    following cells
functions that you      structures that you     activities of daily
influence in your       influence in your       living/participation
treatment of patients   treatment of patients   that you influence
with internal           with internal           in your treatment of
medicine conditions     medicine conditions     patients with internal
in the acute            in the acute            medicine conditions
situation               situation               in the acute situation

Please list in the      Please list in the
following cells         following cells factors
factors of the          of the environment
environment at you      at influence your
influence in your       treatment of patients
treatment of patients   with internal medicine
with internal           conditions in the acute
medicine conditions     situation
in the acute
situation

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.

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

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.

Data Analysis

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

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 7 contain 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.

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, b 710-mobility of joint functions, b 730-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 b 7-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 b 7-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 s7-structures of the nervous system, s4-structures of the cardiovascular, immunological, and respiratory systems, and s7-structures related to movement were 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 chapter d1-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 categories e310-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, and Environmental 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 findings (26,27) 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.~

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 Functions and 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 dl-learning and applying knowledge and 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 component Activities 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)

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 used (18) 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.

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.

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.

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.

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 article was received April 24, 2005, and was accepted April 27, 2006.

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The Bottom Line

The Bottom Line is a translation of study findings for application to clinical practice. It is not intended to substitute for a critical reading of the research article. Summaries are written by members of The Bottom Line Committee.

[Finger ME, Cieza A, Stoll J, et al. Identification of intervention categories for physical therapy, based on the International Classification of Functioning, Disability and Health: a Delphi exercise. Phys Ther. 2006;86:1203-1220.]

What problems did the researchers set out to study, and why?

The International Classification of Functioning, Disability and Health (ICF) provides a recognized framework and classification system that can be used to describe the impact of health and health conditions on functioning and disability. The components of functioning and disability include body functions and structures and activities and participation. The ICF also considers contextual factors, including environmental and personal factors, that interact with health conditions to influence functioning and disability.

As the authors emphasize, pathoanatomic diagnoses, such as those based on the International Classification of Diseases, do not meet the needs of physical therapists, who require a more function-oriented framework as a basis for intervention. The authors hypothesized that the ICF can be used to identify patient problems commonly managed by physical therapists in a common and standardized language. Such a description could lead to lists of ICF categories that describe physical therapist practice.

The purpose of this study was to identify the ICF categories that describe the most common functional problems related to musculoskeletal, neurological, and internal medicine conditions in patients treated by physical therapists in acute, rehabilitation, and community health care settings.

Who participated in this study?

Physical therapists from the German-, French- and Italian-speaking areas of Switzerland who practiced in acute, rehabilitation, and community health care settings and who treated patients with musculoskeletal, neurological, or internal medicine problems. A total of 263 physical therapists participated in at least 1 of the 3 rounds of Delphi exercises. Subjects were divided into 9 groups based on work setting and type of patient problems that they most typically manage.

What new information does this study offer?

The results indicate the areas of functioning and disability that are most commonly targeted by physical 'therapists when managing patients with musculoskeletal, neurological, or internal medicine problems. Across all groups, the greatest consensus was found in the areas of body functions and activities and participation. In most groups, the highest consensus was reached in categories related to movement. For neuromusculoskeletal and movement-related functions and sensation of pain, there was a consensus of 80% or higher in all 9 groups.

There also were differences among the groups. Mental functions, sensory functions, function of the digestive, metabolic, and endocrine systems, learning and applying knowledge, and self-care were areas of important problems for patients with neurological conditions across all settings. Important problems for patients with musculoskeletal conditions were in categories similar to those for patients with neurological involvement, with the addition of the category "acquiring, keeping, and terminating a job." For internal medicine conditions, problem areas for which there was consensus included functions of the cardiovascular, hematological, immunological, and respiratory systems. These findings indicate there were ICF categories that were common to all 3 patient groups as well as categories that were condition specific.

How did the researchers go about the study?

Participating physical therapists were identified by contacting all members of the Swiss Association of Physical Therapy Department Heads and all members of the Swiss Association of Physiotherapy. The authors used a Delphi procedure to conduct a consensus-building 3-round electronic mail survey. In the first round, physical therapists completed open-ended questionnaires to determine the body functions, body structures, activities and participation, and environmental factors that were influenced by physical therapy intervention. Participants were not requested to use ICF language in this round. The participants' answers then were linked to the ICF using standardized procedures.

For the second round, the ICF categories generated after the first round were listed on a closed-ended questionnaire. Information on whether the participant had named the ICF category in the prior round and the percentage of all participants who had endorsed the ICF category also were provided. Participants were asked to take into consideration their own response and the answers from the group to determine whether the ICF category was treated by physical therapists in patients with problems related to one of the diagnostic areas within a given practice setting. The third round was conducted in a manner similar to the second round. After each round, the percentage of participants who endorsed each ICF category was determined. Consensus was defined as endorsement of a category by 80% or more of the participants.

How might the results of the study apply to the practice of physical therapy?

These findings can be used to develop a profile of functioning for individual patients, which could enable physical therapists to tailor their interventions to the patient. By identifying important categories of interventions for homogeneous groups of patients, it may be possible to develop treatment guidelines that are related to particular impairments of body function and structure and to activity limitations and participation restrictions. This may enable physical therapists to develop treatment-based classification systems that can be subjected to further research to develop evidence-based practice guidelines.

The results could help define physical therapist practice and could be used to develop competencies for entry-level practice and for practice within defined specialty and subspecialty areas. This in turn may be useful for defining clinical education experiences for professional training and for clinical residencies and fellowships. Finally, the results could be used to define relevant outcome measures for specific patient groups in specific practice settings.

What are the limitations of the study, and what further research is needed?

The results of this study can be generalized to physical therapists working in Switzerland with patients who have musculoskeletal, neurolegic, or internal medicine conditions in acute, rehabilitation, and community health settings. Research is needed to validate these findings in different countries and settings and with different patient groups. Research also will be needed to determine the influence that the ICF categories will have on future physical therapist practice.

[DOI: 10.2522/ptj.20050134.bl]

ME Finger, Dipl Physio, MSc (Candidate), is Physiotherapist, Rehaklinik Bellikon, 5454 Billikon, Switzerland. Address all correspondence to Ms Finger at: [e-mail].

A Cieza, PhD, is Research Group Leader, Institute for Health and Rehabilitation Sciences, ICF Research Branch, WHO FIC Collaboration Center (DIMDI), Ludwig-Maximilians University, Munich, Germany.

J Stoll, Dipl Physio, MSc (Candidate), is Physiotherapist, PROMEFA AG, Ringgenberg, Switzerland.

G Stucki, MD, is Medical Director, Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians University. EO Huber, Dipl Physio, ex. MHSA, is Medical Therapeutic Director, Institute of Physical Medicine, University Hospital of Zurich, Zurich, Switzerland.

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.

DOI: 10.2522/ptj.20050134

Table 1.

Participants and Response Rate (a)

                      MA     MR     MC     NA      NR     NC

Round 1
  Addressed:
  Participants (n)    70     44     59     33      35     32
  Respondents (n)     47     31     38     24      26     18
  Response rate (%)   67     70     64     73      74     56
    German (n)        38     23     32     20      19      9
    French (n)         7      5      3      3       7      8
    Italian (n)        2      3      3      1       0      1

Round 2
  Addressed:
  Participants (n)    70     44     59     33      35     32
  Respondents (n)     35     30     29     17      22     17
  Response rate (%)   50     68     49     52      63     53
    German (n)        28     23     23     14      16     10
    French (n)         7      4      3      3       6      7
    Italian (n)        0      3      3      0       0      0

Round 3
  Addressed:
  Participants (n)    49     35     39     23      25     20
  Respondents (n)     37     30     30     20      21     18
  Response rate (%)   76     86     77     87      84     90
    German (n)        31     23     22     17      17     10
    French (n)         5      5      5      3       4      8
    Italian (n)        1      2      3      0       0      0

No. of years          14     11     17     13.5    10.5   15
  treating
  patients
  (median)

                                          Total   Distribution of
                      IA      IR   IC     No.     Language (%)

Round 1
  Addressed:
  Participants (n)    46      24   22      365
  Respondents (n)     35      15   10      244
  Response rate (%)   76      63   45       67
    German (n)        33      12    8      194    80
    French (n)         0       3    2       38    16
    Italian (n)        2       0    0       12     5

Round 2
  Addressed:
  Participants (n)    46      24   22      365
  Respondents (n)     32      12    9      203
  Response rate (%)   70      50   41       56
    German (n)        31      10    6      161    79
    French (n)         0       2    3       35    17
    Italian (n)        1       0    0        7     3

Round 3
  Addressed:
  Participants (n)    36      16   11      254
  Respondents (n)     32      14    8      210
  Response rate (%)   89      88   73       83
    German (n)        31      11    5      167    80
    French (n)         0       3    3       36    17
    Italian (n)        1       0    0        7     3

No. of years           6.75   12   12.5
  treating
  patients
  (median)

(a) MA=musculoskeletal/acute, MR=musculoskeletal/rehabilitation,
MC=musculoskeletal/community health care situation,
NA=neurological/acute, NR=neurological/rehabilitation,
NC=neurological/community health care situation, IA=internal
medicine/acute, IR=internal medicine/rehabilitation,
IC=internal medicine/community health care situation.

Table 2.

Consensus Process From First to Third Delphi Rounds (a)

                            MA    MR    MC    NA    NR

Round 1
  Total of identified       162   168   174   201   195
    ICF categories (n)
  ICF categories with         3     3     3     1     6
    a consensus
    [greater than or
    equal to] 80% (n)

Round 2
  ICF categories with        30    43    50    59    62
    a consensus
    [greater than or
    equal to] 80% (n)

Round 3
  ICF categories with        41    50    57    89    80
    a consensus
    [greater than or
    equal to] 80% (n)

Final consensus: ICF
    categories with a
    consensus [greater
    than or equal to] 80%
    per component
  Body Functions (n)         11    16    21    29    29
  Body Structures (n)         6     6     8    13     8
  Activities and             12    20    16    23    24
    Participation (n)
  Environmental               4     3     4    10     9
    Factors 1 (n)
  Environmental               8     5     8    14    10
    Factors 2 (n)

                                                    Total of
                                                    Different
                                                    ICF
                            NC    IA    IR    IC    Categories

Round 1
  Total of identified       190   143   103   116   276
    ICF categories (n)
  ICF categories with         3     5     2     5    14
    a consensus
    [greater than or
    equal to] 80% (n)

Round 2
  ICF categories with        74    20    26    14   107
    a consensus
    [greater than or
    equal to] 80% (n)

Round 3
  ICF categories with        86    37    31    25   133
    a consensus
    [greater than or
    equal to] 80% (n)

Final consensus: ICF
    categories with a
    consensus [greater
    than or equal to] 80%
    per component
  Body Functions (n)         27    15    16     9    46
  Body Structures (n)        10     4     2     4    18
  Activities and             25     5     6     6    38
    Participation (n)
  Environmental               8     6     2     2    11
    Factors 1 (n)
  Environmental              16     7     5     4    19
    Factors 2 (n)

The results are presented at the first and second levels
of the International Classification of Functioning,
Disability and Health (ICF). See Table I footnote for
explanation of abbreviations.

Table 3.

International Classification of Functioning, Disability
and Health (ICF) Categories in the Component Body
Functions Considered as Relevant or Typical to Be
Influenced by Physical Therapy by [greater than or equal to] 80%
of the Participants in at Least One Group (a)

Body Functions                 MA       MR    MC    NA

b110-consciousness functions   -- (b)   --    --    100
b114-orientations function     --       --    --    100
b122-global psychosocial       --       --    --    --
     functions
b126-temperament and           --        83   100   --
     personality functions
b130-energy and drive          97       100   100    95
     functions
b134-sleep functions           --       --     93   --
b140-attention functions       --       --     83   100
b144-memory functions          --       --    --     90
b147-psychomotor functions     --       --    --    --
b152-emotional functions       --       --     97   --
b156-perceptual functions      --        93   100   100
b164-higher-level cognitive    --       --    --    --
     functions
b176-mental functions of       --       --    --    --
     sequencing complex
     movements
b180-experience of self and    92        90    97    95
     time functions
b210-seeing functions          --       --    --     90
b235-vestibular functions      --       --     80    95
b260-proprioceptive function   97        97   100   100
b265-touch function            --       --    --    100
b270-sensory functions         --       --     80    90
     related to temperature
     and other stimuli
b280-sensation of pain         100       93   100    95
b310-voice functions           --       --    --     80
b320-articulation function     --       --    --     80
b410-heart functions           --        83   --    --
b415-blood vessel functions    --       --    --    --
b420-blood pressure            --       --    --    --
     functions
b430-hematological system      --       --    --    --
     functions
b435-immunological system      81       --    --    --
     functions
b440-respiration functions     --        87    80    95
b445-respiratory muscle        --       --    --     90
     functions
b450-additional respiratory    --       --    --    --
     functions (c)
b455T-exercise tolerance       --        97    93    85
      functions
b460-sensations associated     --       --    --    --
     with cardiovascular and
     respiratory systems (d)
b510-ingestion functions       --       --    --     95
b530-weight maintenance        --       --    --    --
     functions
b710-mobility of joint         100       97   100   100
     functions
b715-stability of joint        97        97   100    95
     functions
b720-mobility of bone          --       --    --    --
     functions
b730-muscle power functions    95       100    93   100
b735-muscle tone functions     97        93    97   100
b740-muscle endurance          92        97    97    95
     functions
b755-involuntary movement      --       --     87   100
     reaction functions (e)
b760-control of voluntary      97        97   100   100
     movement functions
b765-involuntary movement      --       --    --     85
     functions
b770-gait pattern functions    --       100   --     95
b780-sensations related to     --       --     90    80
     muscles and movement
     functions
b820-repair functions of       --       --    --    --
     the skin

Body Functions                    NR    NC    IA    IR    IC

b110-consciousness functions       86   --    --    --    --
b114-orientations function        100   --    --    --    --
b122-global psychosocial           90   --    --    --    --
     functions
b126-temperament and              --    --    --     86   --
     personality functions
b130-energy and drive              95   100    91    93   --
     functions
b134-sleep functions              --    --    --    --    --
b140-attention functions          100    94   --    --    --
b144-memory functions              95   --    --    --    --
b147-psychomotor functions        --     89   --    --    --
b152-emotional functions          --     -    --    --    --
b156-perceptual functions         100   100   --    --    --
b164-higher-level cognitive        81    83   --    --    --
     functions
b176-mental functions of           81   --    --    --    --
     sequencing complex
     movements
b180-experience of self and        95   100   --    100   --
     time functions
b210-seeing functions             --    --    --    --    --
b235-vestibular functions         100   100   --    --    --
b260-proprioceptive function      100   100   --    --     88
b265-touch function                95   100   --    --    --
b270-sensory functions             95    83   --    --    --
     related to temperature
     and other stimuli
b280-sensation of pain            100    94    97   100    88
b310-voice functions              --    --    --    --    --
b320-articulation function        --    --    --    --    --
b410-heart functions              --     83    91    93   --
b415-blood vessel functions       --    --     97   --     88
b420-blood pressure               --    --     81    93   --
     functions
b430-hematological system         --    --     84   --    --
     functions
b435-immunological system         --     94    94   --    100
     functions
b440-respiration functions         95    94   100   100   --
b445-respiratory muscle            81   --     94    86   --
     functions
b450-additional respiratory       --    --     94    86   --
     functions (c)
b455T-exercise tolerance          100   100   100   100   --
      functions
b460-sensations associated        --    --    --     93   --
     with cardiovascular and
     respiratory systems (d)
b510-ingestion functions           95   100   --    --    --
b530-weight maintenance           --    --    --     86   --
     functions
b710-mobility of joint            100   100    94   100   100
     functions
b715-stability of joint            90   100   --    --    --
     functions
b720-mobility of bone             --    100   --    --    --
     functions
b730-muscle power functions       100   100    97   100   100
b735-muscle tone functions        100    94    91   --    --
b740-muscle endurance             100   100    84   100   100
     functions
b755-involuntary movement         100   100   --    --    --
     reaction functions (e)
b760-control of voluntary         100   100   --     93    88
     movement functions
b765-involuntary movement          95   100   --    --    --
     functions
b770-gait pattern functions        95   100   --    --    --
b780-sensations related to         86    94   --    --    --
     muscles and movement
     functions
b820-repair functions of          --    --    --    --     88
     the skin

(a) See Table 1 footnote for explanation of abbreviations.

(b) Consensus <80% or no participant named that domain
in the corresponding group.

(c) Defined as functions related to breathing, such as coughing,
sneezing, and yawning.

(d) Defined as sensations such as missing a heart beat,
palpitation, and shortness of breath.

(e) Defined as functions of involuntary contractions of large
muscles or the whole body induced by body position, balance,
and threatening stimuli.

Table 4.

International Classification of Functioning, Disability
and Health Categories in the Component Body Structures Considered
as Relevant or Typical to Be Influenced by Physical Therapy
by [greater than or equal to] 80% of the Participants in at Least
One Group (a)

Body Structures                    MA      MR    MC    NA    NR

s110-structure of brain          -- (b)    --    --   100    81
s120-spinal cord and related     --        --    90    90    86
     structures
s140-structure of sympathetic    --        --    90    --    81
     nervous system
s150-structure of                --        --    86    --    --
     parasympathetic nervous
     system
s320-structure of mouth          --        --    --    90    --
s330-structure of pharynx        --        --    --    80    --
s340-structure of larynx         --        --    --    80    --
s410-structure of                86        90    93    80    --
     cardiovascular system
s420-structure of immune         86        --    --    --    --
     system
s430-structure of respiratory    --        --    83    95    --
     system
s710-structure of head and       --        --    97    80    90
     neck region
s720-structure of shoulder       97        90    --    95    95
     region
s730-structure of upper          --        93    --    90    95
     extremity
s740-structure of pelvic         95        97    --    80    --
     region
s750-structure of lower          95       100    --    85    95
     extremity
s760-structure of trunk          92        93    97    90    95
s770-additional                  --        --    93    --    --
     musculoskeletal
     structures related to
     movement (c)
s810-structure of areas          --        --    --    --    --
     of skin

Body Structures                   NC    IA    IR    IC

s110-structure of brain           94    --    --    --
s120-spinal cord and related      89    --    --    --
     structures
s140-structure of sympathetic     --    --    --    --
     nervous system
s150-structure of                 --    --    --    --
     parasympathetic nervous
     system
s320-structure of mouth           --    --    --    --
s330-structure of pharynx         --    --    --    --
s340-structure of larynx          --    --    --    --
s410-structure of                 --   100   100    --
     cardiovascular system
s420-structure of immune          --    94    --   100
     system
s430-structure of respiratory     89   100   100    --
     system
s710-structure of head and       100    --    --    --
     neck region
s720-structure of shoulder       100    --    --    88
     region
s730-structure of upper          100    --    --    --
     extremity
s740-structure of pelvic          94    --    --    --
     region
s750-structure of lower          100    --    --   100
     extremity
s760-structure of trunk          100    91    --    --
s770-additional                   89    --    --    --
     musculoskeletal
     structures related to
     movement (c)
s810-structure of areas           --    --    --    88
     of skin

(a) See Table 1 footnote for explanation of abbreviations.

(b) Consensus <80% or no participant named that domain
in the corresponding group.

(c) Includes structures such as joints, bones, and muscles.

Table 5.

International Classification of Functioning, Disability
and Health Categories in the Component Activities and
Participation Considered as Relevant or Typical to Be
Influenced by Physical Therapy by [greater than or equal to] 80%
of the Participants in at Least One Group (a)

Activities and Participation       MA        MR    MC    NA    NR

d110-watching                      -- (b)    --    --    --    81
d115-listening                     --        --    --    --    --
d120-other purposeful sensing      --        --    --    --    --
d130-copying                       --        --    --    80    --
d155-acquiring skills              --        93    --    --    90
d160-focusing attention            --        --    --   100    90
d175-solving problems              --        87    --    --    90
d210-undertaking a single task     --        80    --    90    81
d220-undertaking multiple tasks    --        --    --    --    --
d230-carrying out daily routine    89        93    97    95    90
d240-handling stress and other     81        --    97    --    --
     psychological demands
d310-communicating                 --        --    --    80    81
     with/receiving
     spoken messages
d330-speaking                      --        --    --    85    --
d335-producing nonverbal           --        --    --    80    --
     messages
d410-changing basic body           97       100   100   100   100
     position
d415-maintaining a body            92       100    97    95   100
     position
d420-transferring oneself          89       100    --    95    95
d430-lifting and carrying          86        97   100    80    90
     objects
d440-fine hand use                 --        --    --    85    95
d445-hand and arm use              95        90    83   100    95
d450-walking                       97       100   100    95    95
d455-moving around                 86       100    83    95    95
d460-moving around in              --       100    87    80    95
     different locations
d465-moving around using           --        87    --    90    95
     equipment
d470-using transportation          --        90    --    --    --
d510-washing oneself               --        --    --    90    86
d520-caring for body parts         --        80    83    95    81
d530-toileting                     --        --    --    95    95
d540-dressing                      --        93    --   100    90
d550-eating                        --        --    --    95    90
d560-drinking                      --        --    --   100    90
d570-looking after one's health    92        90   100    --    --
d620-acquisition of goods and      --        --    90    --    --
     services
d640-doing housework               --        --    90    --    --
d760-family relationships          --        --    87    --    --
d840-apprenticeship                --        80    --    --    --
d845-acquiring, keeping, and       86        93    90    --    --
     terminating a job
d920-recreation and leisure        97        97   100    --    86

Activities and Participation       NC    IA    IR    IC

d110-watching                      83    --    --    --
d115-listening                     83    --    --    --
d120-other purposeful sensing      83    --    --    --
d130-copying                       --    --    --    --
d155-acquiring skills              --    --    --    --
d160-focusing attention           100    --    --    --
d175-solving problems              --    --    --    --
d210-undertaking a single task     --    --    --    --
d220-undertaking multiple tasks    89    --    --    --
d230-carrying out daily routine    94    81    --    --
d240-handling stress and other     --    --    93    --
     psychological demands
d310-communicating                 --    --    --    --
     with/receiving
     spoken messages
d330-speaking                      --    --    --    --
d335-producing nonverbal           --    --    --    --
     messages
d410-changing basic body          100   100    86    --
     position
d415-maintaining a body           100    90    --    --
     position
d420-transferring oneself          94    97    --    --
d430-lifting and carrying          83    --   100    88
     objects
d440-fine hand use                 89    --    --    --
d445-hand and arm use              94    --    --    --
d450-walking                       94    97   100    88
d455-moving around                 94    --    --    --
d460-moving around in              94    --    93    --
     different locations
d465-moving around using           94    --    --    --
     equipment
d470-using transportation          83    --    --    --
d510-washing oneself               89    --    --    --
d520-caring for body parts         83    --    --    88
d530-toileting                     89    --    --    --
d540-dressing                      94    --    --    --
d550-eating                        89    --    --    --
d560-drinking                      89    --    --    --
d570-looking after one's health    83    --    93    88
d620-acquisition of goods and      --    --    --    --
     services
d640-doing housework               --    --    --    --
d760-family relationships          --    --    --    --
d840-apprenticeship                --    --    --    --
d845-acquiring, keeping, and       --    --    --   100
     terminating a job
d920-recreation and leisure        89    --    --   100

(a) See Table 1 footnote for explanation of abbreviations.

(b) Consensus <80% or no participant named that domain
in the corresponding group.

Table 6.

International Classification of Functioning, Disability and Health
Categories in the Component Environmental Factors I Considered
as Relevant or Typical to Be Influenced by Physical Therapy by
[greater than or equal to] 80% of the Participants in at Least
One Group (a)

Environmental Factors 1          MA        MR    MC    NA    NR

e110-products or substances      -- (b)    --    83    --    --
      for personal consumption
e115-products and technology     97        90    --    95    86
     use in daily living
e120-products and technology     84        --    --    95   100
     for personal indoor and
     outdoor mobility and
     transportation
e310-immediate family            92       100    97    95   100
e315-extended family             --        --    --    80    86
e320-friends                     --        --    --    85    81
e340-personal care providers     --        --    --    90    95
     and personal assistants
e355-health professionals        95        97    93   100   100
e410-individual attitudes of     --        --    80    95    95
     immediate family members
e450-individual attitudes of     --        --    --    95    86
     health professional
e580-health services, systems,   --        --    --    95    --
     and policies

Environmental Factors 1          NC       IA    IR    IC

e110-products or substances      --        81    --    --
      for personal consumption
e115-products and technology     82        81    --    --
     use in daily living
e120-products and technology     82        88    --    --
     for personal indoor and
     outdoor mobility and
     transportation
e310-immediate family            94       100   100    88
e315-extended family             82        --    --    --
e320-friends                     88        --    --    --
e340-personal care providers     94        --    --    --
     and personal assistants
e355-health professionals        88        97    85   100
e410-individual attitudes of     88        --    --    --
     immediate family members
e450-individual attitudes of     --        --    --    --
     health professional
e580-health services, systems,   --        84    --    --
     and policies

(a) See Table 1 footnote for explanation of abbreviations.

(b) Consensus <80% or no participant named that domain
in the corresponding group.

Table 7.

International Classification of Functioning, Disability and Health
Categories in the Component Environmental Factors 2 Considered
as Relevant or Typical to Be Influenced by Physical Therapy by
[greater than or equal to] 80% of the Participants in at Least
One Group (a)

Environmental Factors 2           MA       MR    MC    NA    NR

e110-products or substances       95       90   100   100    90
     for personal consumption
e115-products and technology      -- (b)   --    --    80    90
     for personal use in
     daily living
e120-products and technology      81       --    --    95    95
     for personal indoor and
     outdoor mobility and
     transportation
e155-design, construction,        --       --    --    --    81
     and building products
     and technology of
     buildings for private use
e250-sound                        --       --    --    95    --
e310-immediate family             97       93    97   100    90
e315-extended family              --       --    87    80    --
e320-friends                      84       83    83    80    --
e355-health professionals         97       90    93    95   100
e410-individual attitudes of      95       --    90   100   100
     immediate family members
e415-individual attitudes of      --       --    --    --    --
     extended family members
e420-individual attitudes         --       --    --    --    --
     of friends
e440-individual attitudes of      --       --    --    --    95
     personal care providers
     and personal assistants
e450-individual attitudes of      97       --    --   100    95
     health professionals
e465-social norms, practices,     --       --    --    85    --
     and ideologies
e540-transportation services,     --       --    --    --    --
     systems, and policies
e570-social security services,    --       --    87    95    --
     systems and policies
e575-general social support       --       --    --    80    --
     services, systems and
     policies
e580-health services, systems,    92       83    80   100    90
     and policies

Environmental Factors 2           NC    IA    IR    IC

e110-products or substances      100   100    86   100
     for personal consumption
e115-products and technology     100    80    --    --
     for personal use in
     daily living
e120-products and technology     100    --    --    --
     for personal indoor and
     outdoor mobility and
     transportation
e155-design, construction,        81    --    --    --
     and building products
     and technology of
     buildings for private use
e250-sound                        --    --    --    --
e310-immediate family            100   100   100   100
e315-extended family              94    80    86    --
e320-friends                      88    --    --    --
e355-health professionals        100   100   100   100
e410-individual attitudes of     100    80    --    --
     immediate family members
e415-individual attitudes of      88    --    --    --
     extended amily members
e420-individual attitudes         94    --    --    --
     of friends
e440-individual attitudes of     100    --    --    --
     personal care providers
     and personal assistants
e450-individual attitudes of     100    --    --    --
     health professionals
e465-social norms, practices,     --    --    --    --
     and ideologies
e540-transportation services,     81    --    --    --
     systems, and policies
e570-social security services,   100    --    --    --
     systems and policies
e575-general social support       --    --    --    --
     services, systems and
     policies
e580-health services, systems,   100    93    86   100
     and policies

(b) See Table 1 footnote for explanation of abbreviations.

(b) Consensus <80% or no participant named that domain
in the corresponding group.

Figure 4.

Internal medicine/acute-specific portion of the questionnaire
used in Delphi round 2. The first 2 columns include the
International 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.

Activities and Participation

name of the participant:         Percentage of
                                 participants who
                                 named the listed
                                 the ICF             Is the named ICF
                                 categories          category treated
                                 in the first        by physical
                                 Delphi round as     therapists in
                                 being treated       patients with
                                 In patients         internal medicine
                                 with internal       conditions in the
                                 medicine            acute situation?
                                 conditions in the
                                 acute situation          Yes/No

ICF   ICF categories named in            %
code  the first Delhi round        participants           yes/no
      Chapter 2: General Tasks
d2    and Demands
d230  Carrying out daily                11%
      routine Chapter 3:                3%
d3    Communication
d330  Speaking                          6%
d4    Chapter 4: Mobility               51
      Changing basic body               29%
d410  position
d4100 Lying down                        26%
d4101 Squatting                         3%
d4103 Kneeling                          20%
d4104 Standing                          40%
d4105 Bending                           3%

name of the participant:         Code of participant

ICF   ICF categories named in
code  the first Delhi round      1   3   4   5   6   8
      Chapter 2: General Tasks
d2    and Demands
d230  Carrying out daily                 y
      routine Chapter 3:
d3    Communication
d330  Speaking
d4    Chapter 4: Mobility        y   y   y   y
      Changing basic body                            y
d410  position
d4100 Lying down                         y
d4101 Squatting
d4103 Kneeling                       y
d4104 Standing                       y
d4105 Bending

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.

                                                  Problem   Treatment
Code    ICF Category                              Yes/No     Yes/No

b126    Temperament and personality functions
b130    Energy and drive functions
b156    Perceptual functions
b180    Experience of self and time functions
b260    Proprioceptive function
b280    Sensation of pain                            Y
b410    Heart functions
b440    Respiration functions
b455T   Exercise tolerance functions
b710    Mobility of joint functions                  Y          Y
b715    Stability of joint functions                 Y          Y
b730    Muscle power functions                       Y          Y
b735    Muscle tone functions
b740    Muscle endurance functions
b760    Control of voluntary movement functions
b770    Gait pattern functions                       Y
s410    Structure of cardiovascular system
s720    Structure of shoulder region                 Y
s730    Structure of upper extremity                 y
s740    Structure of pelvic region
s750    Structure of lower extremity                 y
s760    Structure of trunk
d155    Acquiring skills
d175    Solving problems
d210    Undertaking a single task
d230    Carrying out daily routine
d410    Changing basic body position
d415    Maintaining a body position
d420    Transferring oneself
d430    Lifting and carrying objects                 Y
d445    Hand and arm use                             Y
d450    Walking                                      Y
d455    Moving around                                Y
d460    Moving around in different locations         Y
d465    Moving around using equipment
d470    Using transportation
4520    Caring for body parts                        Y
d540    Dressing                                     Y
d570    Looking after one's health
d840    Apprenticeship
d845    Acquiring, keeping, and terminating          Y
          a job
d920    Recreation and leisure                       Y

                                                  Barrier
                                                    or
                                                  Facili-
                                                  tator     Treatment
Code    ICF Category                              Yes/No      Yes/No

e115    Products and technology for personal         y
          use in daily living
e310    Immediate family                             Y
e355    Health professionals                         Y