Validation of the Comprehensive International Classification of Functioning,Disability and Health (ICF) Core Set for Hand Conditions

Abstract

Introduction

The Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions has been developed as a tool to describe functioning in individuals with hand conditions. The purpose of this study was to validate the ICF Core Set in a multicentre study in Germany.

Methods

We conducted a cross-sectional multicentre study involving individuals with various types of hand injuries or disorders from hand trauma units and rehabilitation facilities in Germany. We performed structured patient interviews using the Comprehensive ICF Core Set for Hand Conditions to investigate whether all of its categories are necessary to describe patients' functioning. Patients additionally completed the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).

Results

The study sample comprised 260 individuals (65% men) with a mean age of 46 years. Participants had a mean DASH score of 42.7 (22.25 SD) and a median time since injury or diagnosis of 106 days. Most frequent diagnoses were fractures at forearm, wrist and hand level. We identified patients' problems in all ICF categories of the Comprehensive ICF Core Set for Hand Conditions with a prevalence of at least 10%. Two ICF categories were perceived as missing: ‘b4352 – functions of lymphatic vessels’ and ‘b298 – sensory functions and pain, other specified – neuralgia in upper extremity’.

Discussion

The Comprehensive ICF Core Set for Hand Conditions has been validated in this national multicentre study. All of its categories could thereby be confirmed. Further validation is needed, involving different study samples in different countries worldwide.

Keywords

International Classification of Functioning Disability and Health (ICF)Core Sets hand conditions hand injuries hand therapy

Introduction

Hand problems may originate from conditions of the hand considered as disorders or diseases as well as injuries located directly at hand, wrist or forearm level, such as carpal tunnel syndrome, Dupuytren's disease or fractures. Furthermore, the hand can be limited due to conditions involving the hand considered as diseases or injuries originating external to the hand but affecting the hand, such as rheumatoid arthritis, stroke, Parkinson's disease or brachial plexus injuries, etc. Regardless the type of disease or injury, there are substantial challenges to daily functioning associated with hand conditions. The challenges, patients with hand conditions have to cope with, are not only related to functions of body systems such as mobility of joints, but may also impact on daily routine activities as for example in self-care, work and leisure activities.^1–7

There is an extensive amount of outcome measures to be used in clinical studies and evaluation on hand patients, and no clear consensus exists on which are the most appropriate.^8–11 To guide health professionals working in multidisciplinary teams, in terms of what should be measured in patients with hand conditions, the Comprehensive International Classification of Functioning, Disability and Health (ICF) Core Set for Hand Conditions can serve as a practical tool.^12,13

The Comprehensive ICF Core Set for Hand Conditions has been adopted at the International ICF Consensus Conference convened in Switzerland in May 2009.¹⁴ Twenty-three experts in the field of hand conditions, from 22 different countries, attended the formal decision-making and consensus process, and decided on the selection of ICF categories to be included in the Comprehensive ICF Core Set for Hand Conditions. The Comprehensive ICF Core Set is an agreed-on list of ICF categories grouped into the following components: body functions (b), body structures (s), activities and participation (d), and environmental factors (e) (Figure 1).¹⁵ It aims to describe functioning and disability of patients with hand conditions and to guide multidisciplinary assessments in treatment and rehabilitation of hand patients. The current version of the Comprehensive ICF Core Set contains a set of 117 ICF categories.¹⁶ The Comprehensive ICF Core Set for Hand Conditions has been tested and validated in this national, cross-sectional multicentre study.

Figure 1

The structure of the International Classification of Functioning, Disability and Health (ICF)

The objective of the study was to validate the Comprehensive ICF Core Set for Hand Conditions. The specific aims were (1) to investigate whether all categories of the Comprehensive ICF Core Set for Hand Conditions are necessary to describe functioning of patients with hand conditions; and (2) to explore if there should be other categories included.

Methods

Study design

The study was conducted as a multicentre cross-sectional study collecting patient data in four study centres in Germany. The study protocol and consent forms were approved by the Ethics Committee of the Medical Association, Hamburg and the Ethics Committee of the Ludwig-Maximilians-Universität, Munich. The study was conducted based on the principles of the Declaration of Helsinki.

Sample

Patients were included, if they (1) suffered from a hand condition (as described previously); (2) were at least 18 years of age; (3) had no mental disorder; (4) understood the purpose of the study and (5) signed the informed consent after the whole study was explained to them. To gather information from a wide spectrum of hand conditions, many different diagnoses were included.

Participants were recruited at (1) the Department of Hand Surgery, Plastic and Microsurgery at the BG Trauma Hospital, Hamburg, (2) the Department of Plastic and Hand Surgery, Burns Unit at the BG Clinic Bergmannstrost, Halle, (3) the Department of Hand, Replantation and Microsurgery at the Trauma Hospital, Berlin and (4) at the Institute for Health and Rehabilitation Sciences of the Ludwig-Maximilians-Universität, Munich.

Measures

Health professionals (physicians, physical therapists, occupational therapists and nurses from the respective study centres who were involved in patients' care, as well as a researcher (SK) from the ICF Research Branch) conducted the interviews using the Comprehensive ICF Core Set for Hand Conditions. The Comprehensive ICF Core Set lists 117 ICF categories of which 27 (23%) refer to body functions, 10 (9%) to body structures, 38 (32%) to activities and participation, and 42 (36%) to contextual environmental factors. It has been developed as a tool to describe functioning and disability of individuals with hand conditions, based on a biopsychosocial view. Various types of hand conditions were thereby considered differentiated into (1) conditions of the hand and (2) conditions involving the hand. While the former include disorders or diseases as well as injuries located directly at hand, wrist or forearm level (such as carpal tunnel syndrome, Dupuytren's disease or fractures, etc.), the latter cover diseases or injuries originating external to the hand but affecting the hand (such as rheumatoid arthritis, stroke, Parkinson's disease or brachial plexus injuries, etc.).

The scale to quantify the degree of the patients' problems was a Visual Analogue Scale (VAS) ranging from 0 (no problem) to 100 (total problem). In addition, health professionals were asked to document the specific aspects of functioning that they considered as missing in the Comprehensive ICF Core Set. Sociodemographic data regarding gender, age, marital status, living situation, education status, occupation and setting (inpatient/outpatient) were collected. Disease-related data included type of hand condition, affected side, handedness and grip strength. The patients filled in the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).¹⁷

Data collection

The health professionals conducted the one-to-one interviews in the previously mentioned study centres using the Comprehensive ICF Core Set for Hand Conditions.¹⁶ Health professionals involved in the study were trained in a one-day workshop on the structure and terminology of the ICF and the methods of the data collection. Further, a case example was presented to the health professionals during this workshop, based on which the interview situation was trained in a role-play. Additionally, they were provided with an interview manual, which contained a detailed description of how to perform the interviews as well as examples of how to question the patient during the interview.

Before the interview, the health professionals obtained demographic and clinical data from patients' medical records. The interview itself was conducted in a structured format, i.e. the interviewer rated the degree of patients' problems in every single ICF category from the Comprehensive ICF Core Set for Hand Conditions. For the components body functions and body structures, health professionals' appraisal was solely based on the clinical information retrieved from the medical charts and on their knowledge of the patient (with the exception of the categories referring to the chapter ‘b1 – Mental Functions’, which were rated in dialogue with the patients). Regarding the component activities and participation as well as the contextual environmental factors, the health professionals took into consideration the information derived from the patients. However, the interviewers rated the amount of limitation (or restriction) in activities and participation and the degree of environmental factors being a facilitator or a barrier, from their clinical experience. During the interview, the patients were not provided with the category list. Patients filled in the self-reported DASH questionnaire after the interview.

Analysis

Sociodemographic and disease-related data were analysed using descriptive statistics. The DASH score is thereby reported.

Regarding the ICF categories, absolute and relative frequencies (prevalence) are reported along with their 95% confidence intervals (CI). The level of problem in the different ICF categories of the components body functions, body structures, and activities and participation was dichotomized considering 0 as no problem and values >0 as problem.

Descriptive data analyses were performed with SAS 9.1 (SAS Institute Inc, Cary, NC, USA).

Results

A total study population of 260 participants (169 men, 65%) was recruited in the BG Trauma Hospital, Hamburg (n = 148), the BG Clinic Bergmannstrost, Halle (n = 45), the Trauma Hospital, Berlin (n = 50) and at the Institute for Health and Rehabilitation Sciences in Munich (n = 17). From 260 interviews, 199 (76.6%) were conducted by physicians, 30 (11.5%) by occupational therapists, 12 (4.6%) by physical therapists and two (0.8%) interviews were conducted by nurses. All clinical interviewers were closely involved in patients' care in the respective study centres. A researcher from the ICF Research Branch (SK) conducted 17 (6.5%) interviews as well. Age at interview ranged from 19 to 82 years (mean 46 years). Selected sociodemographic and disease-related data are listed in Table 1.

Table 1

Sociodemographic and disease-related characteristics of the participants (n = 260)

	Number of patients	%
Female	91	35.0
Male	169	65.0
Mean age, years (range)	46 (19–82)
Living status
Living alone	59	22.8
Living not alone	196	75.7
Not available	4	1.5
Occupation
Paid employment	192	73.8
Self-employment	14	5.4
Home/retired	27	10.4
Unemployed	21	8.1
Others	6	2.3
Setting
Inpatient	173	66.5
Outpatient	87	33.5
Handedness
Right-handed	242	93.1
Left-handed	17	6.5
Type of hand condition
Injury of the hand	183	70.4
Disorder/disease of the hand	58	22.3
Injury/disease involving the hand	19	7.3
Affected side
Right hand	127	48.8
Left hand	117	45.0
Both hands	16	6.2

The majority of the patients suffered from injuries of the hand (70.4%). Most frequent diagnoses were fractures at wrist and hand level (19%), fracture at forearm (17%), dislocation, sprain and strain of joints and ligaments (12%), injury of muscle and tendon (12%), and traumatic amputation of wrist and hand (10%) (Table 2). Median time from injury to interview was 103 days for patients having an injury located directly at the hand (n = 233), 97 days for patients having a disorder/disease located directly at the hand (n = 58) and 1040 days (34 months) for patients with an injury/disease originating external to the hand but affecting the hand (n = 19). Table 3 shows time since injury or disease and the mean DASH-Score by type of hand condition. Sixty-seven per cent of the patients were inpatients. No patients were excluded from the analysis.

Table 2

Diagnosis of the participants (n = 260)

ICD 10	Diagnosis	Number of patients	%
S62	Fracture at wrist and hand level	48	18.5
S52	Fracture of forearm	44	16.9
S63	Dislocation, sprain and strain of joints and ligaments at wrist and hand level	31	11.9
S66	Injury of muscle and tendon at wrist and hand level	31	11.9
S68	Traumatic amputation of wrist and hand	26	10.0
S61	Open wound of wrist and hand	21	8.1
L03	Cellulitis of parts of limb	17	6.5
T23	Burn and corrosion of wrist and hand	17	6.5
M89	Algoneurodystrophy	14	5.4
S64	Injuries of nerves at wrist and hand level	13	5.0
M19	Arthrosis	10	3.8
S60	Superficial injury of wrist and hand	10	3.8
G56	Mononeuropathies of upper limb	9	3.5
M65	Synovitis and tenosynovitis	7	2.7
T92	Sequelae of injuries of upper limb	7	2.7

Note: Multiple diagnoses per participant possible

Table 3

Time since injury or diagnosis and DASH-Score, stratified for type of hand condition

	Injury of the hand (n = 183)	Condition of the hand (n = 58)	Injury or condition involving the hand (n = 19)	Total study population (n = 260)
DASH-Score^†, mean (SD)	40.8 (22.42)	46.4 (19.99)	48.4 (24.67)	42.7 (22.25)
Time since injury/diagnosis
In days, median^‡	103	97	1040	106
In months, median^‡	3.4	3.2	34.2	3.5

DASH = Disabilities of the Arm, Shoulder and Hand Questionnaire

^†Data analysed, n = 254

^‡Data analysed, n = 250

Health professionals reported for all ICF categories of the Comprehensive ICF Core Set for Hand Conditions either impairments, limitations (or restrictions) or noted environmental factors as facilitators or barriers in at least 10% of the study population. Table 4 shows the ICF categories of the Comprehensive ICF Core Set for Hand Conditions in which patients' problems were documented in more than 70% of the study population. ICF categories of the Comprehensive ICF Core Set for Hand Conditions showing the highest prevalence were: e310 ‘Immediate family’ (93.1%), e355 ‘Health professionals’ (91.5%), s7302 ‘Structure of the hand’ (91.2%), b730 ‘Muscle power functions’ (86.2%) and b7100 ‘Mobility of a single joint’ (84.6%). Only six of the ICF Core Set categories were affected with percentages <20.0% (Table 5). Table 6 lists the ICF categories showing a prevalence of <70.0% and ≥20.0%.

Table 4

ICF Core Set categories being relevant in >70% of patients

ICF Code	Title	n	%	[95% CI]
b7100	Mobility of a single joint	220	84.6	[79.73; 88.49]
b7101	Mobility of several joints	208	80.0	[74.72; 84.41]
b730	Muscle power functions	224	86.2	[81.43;8 9.83]
b740	Muscle endurance functions	216	83.1	[78.05; 87.15]
s7302	Structure of hand	237	91.2	[87.08; 94.03]
d230	Carrying out daily routine	199	76.5	[71.02; 81.28]
d430	Lifting and carrying objects	210	80.8	[75.54; 85.10]
d4402	Manipulating	201	77.3	[71.84; 81.98]
d4451	Pushing	185	71.2	[65.37; 76.32]
d4454	Throwing	186	71.5	[65.77; 76.68]
d4455	Catching	213	81.9	[76.79; 86.13]
d630	Preparing meals	195	75.0	[69.40; 79.87]
d640	Doing housework	210	80.8	[75.54; 85.10]
d650	Caring for household objects	206	79.2	[73.89; 83.72]
d840_d859	Work and employment	202	77.7	[72.25; 82.33]
d920	Recreation and leisure	188	72.3	[66.57; 77.39]
e310	Immediate family	242	93.1	[89.32; 95.58]
e320	Friends	208	80.0	[74.72; 84.41]
e355	Health professionals	238	91.5	[87.52; 94.35]
e410	Individual attitudes of immediate family members	205	78.9	[87.08; 94.03]
e420	Individual attitudes of friends	193	74.2	[68.59; 79.17]
e450	Individual attitudes of health professionals	185	71.2	[65.37; 76.32]

Table 5

ICF Core Set categories being relevant in <20.0% of patients

ICF Code	Title	n	%	[95% CI]
s410	Structure of cardiovascular system	33	12.7	[81.43; 89.83]
s710	Structure of head and neck region	26	10.0	[78.05; 87.15]
s720	Structure of shoulder region	47	18.1	[68.59; 79.17]
s7300	Structure of upper arm	48	18.5	[65.37; 76.32]
d810_d839	Education	46	17.7	[79.73; 88.49]
e335	People in subordinate positions	51	19.6	[74.72; 84.41]

Table 6

ICF Core Set categories being relevant in <70.0% and ≥20.0% of the patients

ICF Code	Title	n	%	[95% CI]
Body functions
b134	Sleep functions	120	46.2	[40.19; 52.23]
b152	Emotional functions	122	46.9	[40.95; 52.99]
b1801	Body image	84	32.3	[26.92; 38.21]
b260	Proprioceptive function	61	23.5	[18.72; 28.98]
b265	Touch function	114	43.9	[37.95; 49.92]
b2700	Sensitivity to temperature	95	36.5	[30.92; 42.55]
b2701	Sensitivity to vibration	81	31.2	[25.83; 37.02]
b2702	Sensitivity to pressure	121	46.5	[40.57; 52.61]
b2703	Sensitivity to a noxious stimulus	93	35.8	[30.19; 41.76]
b280	Sensation of pain	153	58.9	[52.78; 64.66]
b415	Blood vessel functions	55	21.2	[16.63; 26.52]
b715	Stability of joint functions	95	36.5	[30.92; 42.55]
b720	Mobility of bone functions	113	43.5	[37.57; 49.54]
b735	Motor tone functions	145	55.8	[49.69; 61.68]
b760	Control of voluntary movement functions	90	34.6	[29.09; 40.58]
b765	Involuntary movement functions	87	33.5	[28.00; 39.40]
b780	Sensations related to muscles and movement functions	105	40.4	[34.60;46.45]
b810	Protective functions of the skin	83	31.9	[26.55; 37.82]
b820	Repair functions of the skin	63	24.2	[19.42; 29.79]
b830	Other functions of the skin	101	38.9	[33.13; 44.89]
b840	Sensation related to the skin	103	39.6	[33.86; 45.67]
b860	Functions of nails	74	28.5	[23.32; 34.23]
Body structures
s120	Spinal cord and related structures	53	20.4	[15.94; 25.70]
s7301	Structure of forearm	104	40.0	[34.23; 46.06]
s810	Structure of areas of skin	121	46.5	[40.57; 52.61]
s830	Structure of nails	61	23.5	[18.72; 28.98]
Activities and participations
d170	Writing	125	48.1	[42.08; 54.13]
d360	Using communication devices and techniques	112	43.1	[37.20; 49.15]
d410	Changing basic body position	73	28.1	[22.96; 33.83]
d420	Transferring oneself	66	25.4	[20.48;31.01]
d4400	Picking up	167	64.2	[58.24; 69.81]
d4401	Grasping	176	67.7	[61.79; 73.08]
d4403	Releasing	79	30.4	[25.11; 36.23]
d4408	Fine hand use, other specified – pinch grip	175	67.3	[61.39; 72.72]
d4450	Pulling	180	69.2	[63.37; 74.53]
d4452	Reaching	138	53.1	[47.01; 59.05]
d4453	Turning or twisting the hands or arms	165	63.5	[57.45; 69.08]
d455	Moving around	107	41.2	[35.34; 47.22]
d465	Moving around using equipment	111	42.7	[36.83; 48.77]
d470	Using transportation	76	29.2	[24.04; 35.03]
d475	Driving	178	68.5	[62.58; 73.81]
d510	Washing oneself	151	58.1	[52.00; 63.91]
d520	Caring for body parts	157	60.4	[54.33; 66.14]
d530	Toileting	101	38.9	[33.13; 44.89]
d540	Dressing	165	63.5	[57.45; 69.08]
d550	Eating	178	68.5	[62.58; 73.81]
d560	Drinking	114	43.9	[37.95; 49.92]
d570	Looking after one's health	68	26.2	[21.19; 31.82]
d620	Acquisition of goods and services	161	61.9	[55.89; 67.61]
d660	Assisting others	128	49.2	[43.21; 55.27]
d7	Interpersonal interactions and relationships	65	25.0	[20.13; 30.60]
Environmental factors
e110	Products or substances for personal consumption	122	46.9	[40.95; 52.99]
e115	Products and technology for personal use in daily living	131	50.4	[44.35; 56.41]
e120	Products and technology for personal indoor and outdoor mobility and transportation	134	51.5	[45.49; 57.55]
e125	Products and technology for communication	144	55.4	[49.31; 61.30]
e130	Products and technology for education	80	30.8	[25.47; 36.63]
e135	Products and technology for employment	115	44.2	[38.32; 50.31]
e140	Products and technology for culture, recreation and sport	129	49.6	[43.59; 55.65]
e150	Design, construction and building products and technology of buildings for public use	78	30.0	[24.75; 35.83]
e155	Design, construction and building products and technology of buildings for private use	69	26.5	[21.54; 32.22]
e165	Assets	99	38.1	[32.39; 44.11]
e225	Climate	105	40.4	[34.60; 46.45]
e315	Extended family	171	65.8	[59.81; 71.27]
e325	Acquaintances, peers, colleagues, neighbours and community members	164	63.1	[57.06; 68.71]
e330	People in positions of authority	125	48.1	[42.08; 54.13]
e340	Personal care providers and personal assistants	65	25.0	[20.13;30.60]
e345	Strangers	63	24.2	[19.42; 29.79]
e360	Health-related professionals	69	26.5	[21.54; 32.22]
e425	Individual attitudes of acquaintances, peers, colleagues, neighbours and community members	147	56.5	[50.46; 62.43]
e430	Individual attitudes of people in positions of authority	113	43.5	[37.57; 49.54]
e440	Individual attitudes of personal care providers and personal assistants	60	23.1	[18.37; 28.57]
e445	Individual attitudes of strangers	54	20.8	[16.28; 26.11]
e455	Individual attitudes of health-related professionals	69	26.5	[21.54; 32.22]
e460	Societal attitudes	72	27.7	[22.61; 33.43]
e465	Social norms, practices and ideologies	62	23.9	[19.07; 29.38]
e525	Housing services, systems and policies	52	20.0	[15.59; 25.28]
e530	Utilities services, systems and policies	76	29.2	[24.04; 35.03]
e535	Communication services, systems and policies	100	38.5	[32.76; 44.50]
e540	Transportation services, systems and policies	112	43.1	[37.20; 49.15]
e550	Legal services, systems and policies	71	27.3	[22.25; 33.02]
e555	Associations and organizational services, systems and policies	52	20.0	[15.59; 25.28]
e570	Social security services, systems and policies	113	43.5	[37.57; 49.54]
e575	General social support services, systems and policies	87	33.5	[28.00; 39.40]
e580	Health services, systems and policies	170	65.4	[59.42; 70.91]
e585	Education and training services, systems and policies	63	24.2	[19.42; 29.79]
e590	Labour and employment services, systems and policies	90	34.6	[29.09;40.58]

Note: ICF categories showing a prevalence ≥50.0% are in bold

Health professionals documented the following specific aspects of functioning as missing in the Comprehensive ICF Core Set for Hand Conditions: swelling in arms and hands, problems due to protective posture, increased hair growth, neuralgia in upper extremity and lymph functions in upper extremity. Consequently, the ICF categories ‘b4352, – Functions of lymphatic vessels’ and ‘b298 – Sensory functions and pain, other specified – neuralgia in upper extremity’ were added to the Comprehensive ICF Core Set of Hand Conditions. Table 7 shows the validated version of the Comprehensive ICF Core Set for Hand Condition.

Table 7

Validated version of the comprehensive ICF Core Set for Hand Conditions

ICF Code	Title
Body Functions
b134	Sleep functions
b152	Emotional functions
b1801	Body image
b260	Proprioceptive function
b265	Touch function
b2700	Sensitivity to temperature
b2701	Sensitivity to vibration
b2702	Sensitivity to pressure
b2703	Sensitivity to a noxious stimulus
b280	Sensation of pain
b289	Sensory functions and pain, other specified – neuralgia in upper extremity
b415	Blood vessel functions
b4352	Functions of lymphatic vessels
b7100	Mobility of a single joint
b7101	Mobility of several joints
b715	Stability of joint functions
b720	Mobility of bone functions
b7300	Power of isolated muscles and muscle groups
b7301	Power of muscles of one limb
b735	Muscle tone functions
b740	Muscle endurance functions
b760	Control of voluntary movement functions
b765	Involuntary movement functions
b780	Sensations related to muscles and movement functions
b810	Protective functions of the skin
b820	Repair functions of the skin
b830	Other functions of the skin
b840	Sensation related to the skin
b860	Functions of nails
Body structures
s120	Spinal cord and related structures
s410	Structure of cardiovascular system
s710	Structure of head and neck region
s720	Structure of shoulder region
s7300	Structure of upper arm
s7301	Structure of forearm
s7302	Structure of hand
s770	Additional musculoskeletal structures related to movement
s810	Structure of areas of skin
s830	Structure of nails
Activities and participation
d170	Writing
d230	Carrying out daily routine
d360	Using communication devices and techniques
d410	Changing basic body position
d420	Transferring oneself
d430	Lifting and carrying objects
d4400	Picking up
d4401	Grasping
d4402	Manipulating
d4403	Releasing
d4408	Fine hand use, other specified
d4450	Pulling
d4451	Pushing
d4452	Reaching
d4453	Turning or twisting the hands or arms
d4454	Throwing
d4455	Catching
d4458	Hand and arm use, other specified
d455	Moving around
d465	Moving around using equipment
d470	Using transportation
d475	Driving
d510	Washing oneself
d520	Caring for body parts
d530	Toileting
d540	Dressing
d550	Eating
d560	Drinking
d570	Looking after one's health
d620	Acquisition of goods and services
d630	Preparing meals
d640	Doing housework
d650	Caring for household objects
d660	Assisting others
d7	Interpersonal interactions and relationships
d810 – d839	Education
d840 – d859	Work and employment
d920	Recreation and leisure
Environmental factors
e110	Products or substances for personal consumption
e115	Products and technology for personal use in daily living
e120	Products and technology for personal indoor and outdoor mobility and transportation
e125	Products and technology for communication
e130	Products and technology for education
e135	Products and technology for employment
e140	Products and technology for culture, recreation and sport
e150	Design, construction and building products and technology of buildings for public use
e155	Design, construction and building products and technology of buildings for private use
e165	Assets
e225	Climate
e310	Immediate family
e315	Extended family
e320	Friends
e325	Acquaintances, peers, colleagues, neighbours and community members
e330	People in positions of authority
e335	People in subordinate positions
e340	Personal care providers and personal assistants
e345	Strangers
e355	Health professionals
e360	Other professionals
e410	Individual attitudes of immediate family members
e420	Individual attitudes of friends
e425	Individual attitudes of acquaintances, peers, colleagues, neighbours and community members
e430	Individual attitudes of people in positions of authority
e440	Individual attitudes of personal care providers and personal assistants
e445	Individual attitudes of strangers
e450	Individual attitudes of health professionals
e455	Individual attitudes of other professionals
e460	Societal attitudes
e465	Social norms, practices and ideologies
e525	Housing services, systems and policies
e530	Utilities services, systems and policies
e535	Communication services, systems and policies
e540	Transportation services, systems and policies
e550	Legal services, systems and policies
e555	Associations and organizational services, systems and policies
e570	Social security services, systems and policies
e575	General social support services, systems and policies
e580	Health services, systems and policies
e585	Education and training services, systems and policies
e590	Labour and employment services, systems and policies

Note: Additionally included ICF categories are in bold

Discussion

The first version of the Comprehensive ICF Core Set for Hand Conditions, adopted in May 2009 has been validated in this national cross-sectional study. Thereby, all ICF categories of the Comprehensive ICF Core Set for Hand Conditions were confirmed. Thus, it has been shown by this study that the Comprehensive ICF Core Set for Hand Conditions does not contain any redundant ICF category. The results of this study further illustrate that among the included study population, only six ICF categories of the Comprehensive ICF Core Set for Hand Condition were less frequently affected. Nevertheless, with a prevalence of impairment or limitation in 10–20% of the study population, these ICF categories remain as confirmed in the Comprehensive ICF Core Set for Hand Conditions.

Half of the 22 ICF categories in which patients' problems were documented with a prevalence of more than 70% refer to the component activities and participation. Aspects predominantly affected were related to (fine) hand use, domestic life activities, employment and leisure activities. Difficulties in these areas have also been found in other studies that explored the consequences of various types of hand conditions.^1–4,18,19 The majority of our study population experienced injuries of the hand, and the structures primarily affected were joints, bones, muscles, tendons and ligaments. Therefore, it is less surprising that mobility of joints, muscle power and endurance as well as structure of the hand were the central aspects identified among the components body functions and structures.

The Comprehensive ICF Core Set for Hand Conditions lists 42 different environmental factors potentially relevant to individuals with hand conditions. Environmental factors, in general, closely interact with functioning and disability, and its impact on a person's performance might either be in a facilitating or restricting way.¹⁵ In our study, at least one-fourth of the participants stated 81% of these environmental factors as relevant (either as a facilitator or a barrier, or both) with respect to the health disorder they experienced. Thereof, support and attitudes of immediate family members, friends and health professionals were documented as most relevant, which is in line with other studies, describing attitudes and support of family, friends, colleagues or health professionals, as essential for a person's ability to cope with the effects of the disease.^20–22 Thus, to provide high-quality patient care, environmental factors' impact needs to be considered when planning a patient's rehabilitative treatment process.²³

The health professionals were asked to report the areas of functioning they consider as missing in the Comprehensive ICF Core Set. From the aspects documented by the health professionals, lymph functions and neuralgia in upper extremity could be taken into account by including the ICF categories ‘b4352 – Functions of lymphatic vessels’ and ‘b298 – Sensory functions and pain, other specified – neuralgia in upper extremity’ to the list of categories contained in the Comprehensive ICF Core Set for Hand Condition. Increased hair growth (similar as increased pigmentation) refers to ‘b810 – Protective functions of the skin’, which is already included in the Comprehensive ICF Core Set. Even though increased hair growth might lead to aesthetic complaints from the patients' point of view, we do not consider ‘b1801 – Body image’ as the adequate ICF category to choose for this aspect. The category ‘b1801 – Body image’ refers to chapter b1 Mental functions and according to its description, this category includes ‘Specific mental functions related to the representation and awareness of one's body’.¹⁵ Increased hair growth, however, does not cover the mental aspect and therefore the authors reached consent that it would be best attributed to ‘b810 – Protective functions of the skin’. The aspects swelling in arms and hands, and problems due to protective posture are not covered by the ICF.

Another reason for considering the ICF Core Sets for Hand Conditions as helpful in clinical patient evaluation is their assistance when deciding on the appropriate outcome measure. The content of outcome measures frequently used can be analysed by linking its items to the ICF. As a consequence, different outcome measures become comparable.²⁴ Comparing the content of the outcome measures with the categories included in the ICF Core Set (informing about what should be measured) tells us which of the important functioning areas are captured, and which are not captured in a certain outcome measure, and thus facilitates the decision on the adequate outcome measure to choose.

Study limitations

Some issues need to be considered when interpreting these results. First, a convenience sampling procedure combined with a stratified sampling procedure was used. Therefore, the results of the study may not be representative. For example, there is a high proportion of inpatients included in our study sample, which indicates that the population had severe hand conditions. This is related to the study centres involved in the study, which were mainly trauma hospitals. Future studies need to address this issue by including different health and care institutions.

Second, the majority of the study population (70%) of this national validation study were individuals with injuries of the hand. The proportion of patients suffering from injuries or conditions originating external to the hand but affecting the hand is under-represented. Thus, we underline that additional testing of the ICF Core Sets for Hand Conditions is required in study populations with different distributions regarding the health conditions included.

Third, we solely used the DASH Score to describe the patient population and though this instrument was developed to ‘measure physical function and symptoms in people with […] musculoskeletal disorders of the upper limb’,²⁵ seven per cent of our study population with neurological conditions also filled in the DASH Questionnaire. The DASH Score potentially might be of use in further statistical data analyses.

Last, this study has only been performed in Germany. Therefore, other results could be found in other countries and settings as well as from different perspectives (e.g. patient perspective).

Conclusion

The Comprehensive ICF Core Set for Hand Conditions has been tested and validated in this multicentre study conducted in Germany. Based on our findings, all ICF categories of the Comprehensive ICF Core Set were confirmed, and two more ICF categories were added to the list of categories. Further validation studies are needed to gain representative results with respect to different cultures and hand conditions.

Concerning the future use of the Comprehensive ICF Core Set of Hand Condition, it is envisaged that the ICF Core Set serves as a reference tool for selecting potentially relevant aspects of functioning and disability to be drawn upon if necessary, to describe functioning for a specific patient with a specific hand condition in a specific situation.

Footnotes

Acknowledgements

We thank all physicians, nurses, physical therapists and occupational therapist who performed the patient interviews in the participating study centres. Our additional thanks go to Monika Dangers from the BG Trauma Hospital, Hamburg for her encouragement during data collection.

We also thank Caroline Bauer, Fares Day, Michaela Hönig, Silke Joachimsthaler and René Mittrach for supporting us in the patient recruitment process and Michaela Coenen for reviewing the manuscript.

Our special thanks go to Werner Plinske from the Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW) for his support during the whole project and to the German Social Accident Insurance (DGUV) for funding this project.

Sources of funding: This study was funded by the German Social Accident Insurance (DGUV).

Competing interest: None declared.

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