An examination of concepts in vocational rehabilitation that could not be linked to the ICF based on an analysis of secondary data

Abstract

BACKGROUND:

In the last few years the International Classification of Functioning, Disability and Health (ICF) has become a widely known and useful reference classification in vocational rehabilitation. It would be equally important to know which aspects of work-related health information cannot be assigned to distinct ICF categories.

OBJECTIVE:

The objective of this study is to examine the concepts derived from three studies conducted within the ICF Core Set for vocational rehabilitation project, which could not be linked to distinct ICF codes in order to complement the current understanding of functioning in vocational rehabilitation.

METHODS:

Secondary data analysis of the concepts from the systematic literature review, expert survey and patient focus group study of the ICF Core Set for vocational rehabilitation project that were marked as nd = not definable, nc = not covered or pf = personal factor. Nd-concepts were assigned to the biopsychosocial model of the ICF; additional ICF categories were formulated where needed. Nc-concepts were grouped into common themes not covered by the ICF. Pf-categories were linked to a proposed personal factors classification.

RESULTS:

1093 nd-concepts were matched to overarching terms in the ICF, and “other specified”-categories were detailed. 1924 pf-concepts were linked to 31 second level categories of a proposed personal factors classification. 441 nc-concepts were grouped into six themes including the concept of well-being and attributes related to processes and time.

CONCLUSIONS:

With concepts that emerged from the secondary analysis of data gathered during the vocational rehabilitation ICF Core Set project, we have enriched the ICF model with constructs specific to vocational rehabilitation. However, additional research is needed to further explore personal factors specific to vocational rehabilitation. The influence of themes complementary to the ICF such as well-being and quality of life on return-to-work should be further investigated.

Keywords

International Classification of Functioning disability and health content validity vocational rehabilitation return-to-work personal factors environmental factors

1 Introduction

Although multiple definitions of vocational rehabilitation (VR) exist, VR is commonly viewed as a multidisciplinary intervention that aims to optimize return-to-work (RTW) or to maintain the work status of a person with a disability [1 –3]. VR is thereby seen as fundamental in work disability management [4]. The process of returning to work after an illness or an injury is complex, and may drag on over a long period of time. Not only does it involve multiple stakeholders e.g. from the medical field, social security system and workplace, the varying impact of a wide range of health conditions on work participation poses a challenge to VR [5 –7]. To facilitate successful VR outcomes, communication between the various stakeholders along the continuum of care is essential [8]. In addition, it would be beneficial to have an overarching conceptual model with a common language to help structure and coordinate such a complex process in a purposeful way.

The International Classification of Functioning,Disability and Health (ICF) [9], by the World Health Organization (WHO) is based on a biopsychosocial conceptual model and offers an international standard for conceptualizing and classifying functioning anddisability [10]. The ICF is a comprehensive classification system that is organized in a hierarchical fashion and according to the components of Body functions, Body structures, Activities and Participation, Environmental factors, and to chapter, second, third and fourth levels (see Fig. 1). The level of detail increases when going from the chapter to the fourth level [9]. The biopsychosocial model also includes the component of Personal factors; however the ICF currently does not contain categories of Personal factors.

The ICF provides 1,424 categories, of which 362 are defined at the second level (e.g. d850 Remunerative employment) and 1,062 at the third or fourth level (e.g. d8500 Self-employment). Each category comprises of an alphanumeric code.

In addition to the “defined” categories there are, so-called “other specified” categories that are uniquely identified by a code ending with the number 8 (e.g. d8508 Remunerative employment, other specified) and so-called “unspecified” categories that are identified by a code ending with the number 9 (e.g. d8509 Remunerative employment, unspecified) [11]. An “other specified” category is used to code an aspect of functioning that is not definable by any of the categories within the block of categories in which it is found, and allows the further specification of the category. An “unspecified” category is used when an aspect of functioning fits the allocated block, but there is insufficient information to enable the assignment of this aspect of functioning to any of the defined categories in the block. One issue presented by the categories with codes ending in “8” and “9” is that they are setting-specific and therefore complicate the comparison of data or information exchange between settings or among stakeholders.

Since 2001, the ICF has spread steadily among health professionals and in various health care settings as well as in health research. The ICF has found utilityin facilitating communication between stakeholders, structuring rehabilitation plans, goal-setting and clarifying team roles, as well as in documenting functioning [12 –15]. The use of the ICF has also proven applicable in diverse health or health-related fields, such as education, disability evaluation and VR [16 –20]. In addition to its clinical use, the ICF classification was designed to be used as a statistical tool and a research tool to document, compare and combine health information from different sources.

Increasing evidence also encourages the use of the ICF to structure VR interventions and processes. Subsequently, more and more ICF-based tools are being developed for VR. These tools include, for example, short lists of ICF categories, so-called ICF core sets for VR [21].

Since its finalization in 2010, the content validity of the ICF core sets for VR has been confirmed in a number of studies [22, 23], and ICF-based questionnaires and ICF-based documentation tools have been developed. In addition, questionnaires commonly used in VR have been linked to the ICF to quantify selected categories [24 –26].

Nevertheless, the question remains whether the ICF classification is able to capture, evaluate and document the whole lived experience of a person in complex settings such as VR. This concern is shared by professionals and researchers alike, who fault the ICF for not including enough work-specific ICF categories, for example, to describe specific work tasks or the workplace itself or Environmental factors such as work demands [27, 28]. Another crucial issue is the absence of Personal factors categories within the ICF, since the influence of Personal factors on RTW outcomes is undisputed [27 , 30].

To address these issues and to expand our under-standing of the lived experience of persons engaged in VR, it would be valuable to gain more insight into concepts or variables that go beyond distinct ICF codes.

Hence the objective of this study is to examine the concepts derived from three studies conducted within the project to develop the ICF core set for VR and which could not be linked to distinct ICF codes, in order to complement the current understanding of functioning in VR.

2 Methodology

The data we re-analyzed for this study were originally gathered in three of four studies conducted in the first phase of the project to develop the ICF core set for VR, i.e. a patient focus group study, an expert survey and a systematic literature review (see Table 1) [31 –33].

Developing ICF core sets is one approach to address the issue of the impractical large number of codes in the ICF [34, 35]. ICF core sets represent evidence-based and consensus-driven lists of selected ICF categories that capture the full spectrum of variables relevant to describe the functioning of individuals with a distinct health condition, or receiving specific health care or in a health-related setting. An ICF core set development project commonly consists of four so-called “preparatory” studies [34, 35]. Their aim is to identify the most relevant ICF categories that describe the lived experience of individuals from four different perspectives –the patient perspective, the expert perspective, the perspective of researchers and the perspective of the clinic. The ICF categories identified in all four studies are generally presented to a group of international experts who, in a structured consensus process, decide which of those categories are finally included in the respective ICFcore set.

To identify the ICF categories in the preparatory studies, concepts derived from the data i.e. health and health-related information collected in the preparatory studies, had to be “coded” using the ICF. This process of coding health information to distinct ICF codes is called linking and follows established linking rules(see Table 2) [36].

Considering the objective of the study outlined in this paper, we used only data from the patient focus group study, the expert survey and the systematic literature review for the secondary analysis. This was because no linking was done on the data from the fourth preparatory study. In this cross sectional study, the data was collected using an ICF-checklist that already included defined ICF categories [37].

2.1 Description of the source studies

2.1.1 Study number one

A patient focus group study to evaluate the perspective of the patients: Seven focus groups were conducted with 26 participants who were participating in a VR intervention at the time. Participants were encouraged to discuss the most relevant problems they encountered during their participation in VR using six questions reflecting the components of the ICF (Body function, Body structure, Activity and Participation, Environmental factors and Personal factors). The discussion was recorded and transcribed verbatim. Concepts were identified and then coded to the most appropriate ICF category. The study yielded a total of 4,813 relevant concepts which were then linked to a total of 160 different second-level ICF categories. 1,152 concepts that could not be assigned to an existing ICF code were marked either as a personal factor (pf), not definable (nd) or not covered by the ICF (nc) (see Table 2: Linking rules).

2.1.2 Study number two

An international expert survey to evaluate the perspective of the experts: An internet-based survey was conducted with 151 VR experts from six WHO Regions. The experts were asked to indicate the most relevant problems their patients encounter in VR. The six survey questions related to the components of the ICF (Body function, Body structure, Activity and Participation, Environmental factors and Personal factors). The expert statements were analyzed; concepts were identified and then linked to the most appropriate ICF category. The study yielded a total of 101 different second-level ICF categories that corresponded toconcepts mentioned by at least 5% of the participants. 899 concepts that could not be assigned to an existing ICF code were marked either as pf, nd or nc.

2.1.3 Study number three

A systematic review to evaluate the evidence from the literature: The aim of this study was to identify patient-reported and clinician-reported outcomes in VR studies, and to identify the aspects of functioning frequently addressed in those outcomes. From the 250 articles identified, 648 measures were extracted yielding a total of 10,582 concepts. These concepts were linked to 87 different second-level ICF categories. Like study numbers one and two, 1,407 concepts that could not be assigned to an existing ICF code were marked as either pf, nd or nc.

The data we looked at in this study include those concepts from the three source studies that were marked as pf, nd or nc (Table 1). Since the objective of the source studies was to identify distinct ICF categories, these pf, nd or nc-coded concepts were not analyzed.

Although uncommon, we decided to analyze combined data retrieved from the three different source studies. The source studies were conducted within the VR ICF Core Set project, and in this project, the data i.e. the ICF categories identified in each study, were also combined. In turn, this combined list of categories served as the basis for deciding which categories should be included in the ICF Core Set for VR. Thus, combining the data from the source studies i.e. concepts coded as pf, nd or nc for the secondary analysis performed in this study, is consistent with the methodology applied in the initial project. Moreover, these source studies were performed to also reflect different perspectives in describing the functioning of a person engaged in VR. We also made an effort to examine the concepts coded as pf, nd or nc as comprehensively as possible. This meant analyzing data from all three source studies, each one representing three difference perspectives.

2.2 Data preparation

In a first step we investigated the concepts previously linked as nd, pf or nc from the source studies, and decided that it was meaningful to analyze them in depth as well as separately. These concepts were allocated to three predetermined groups:

Group one: Concepts previously linked as nd or not definable, meaning that the concept was unable to be assigned to a defined ICF code.

Group two: Concepts previously linked as pf-personal factor.

Group three: Concepts that are not covered in the context of the ICF, thus marked nc.

Before combining the nds, pfs or ncs from the three source studies, we assigned a unique alphanumeric code to each concept starting with two letters that indicated the specific study from which the concept originated and followed by four numbers that referred to the numerical order within the source study. For example SR0001 would indicate the first concept from the systematic review. This numbering enabled us to identify the source study at any time during the analysis.

In a second step the concepts marked as nd in each of the three studies were combined in a single data pool called nd-pool. The same was done with the pf and nc concepts resulting in a pf-pool and an nc-pool, respectively (Fig. 2).

2.3 Process of examining the concepts

Due to the differing nature of the nd, pf and nc-pools we decided to use specific methodological approaches such as triangulation, classical content analysis, and linking of concepts to an existing personal factors classification to understand the content of each individual data pool and its relation to the ICF.

2.3.1 Nd-pool

The concepts marked as nd are those concepts that are covered by overarching parts, components or chapters of the ICF but contain insufficient information to be assigned to a specific ICF code. In addition, some nd-concepts are described in such detail that they do not fit into a distinct ICF category, thus nd.

To better understand their relation to the ICF, nd-concepts were examined in a consensus meeting involving five researchers who were familiar with the ICF and VR, and grouped according to common themes. If appropriate, sub-themes were formulated. These themes and sub-themes were then assigned to the ICF model by one researcher (MF). Themes that had clear specifications were formulated as “8”-codes, e.g. d8508 Remunerative employment_other specified_heavy work. The assignment of themes to the ICF was then evaluated by two independent researchers (RE, MS). Inconsistencies were discussed until consensus was reached [38].

2.3.2 Pf-pool

The analysis of the pf-concepts involved grouping them according to the personal factors classification proposed by Geyh et al. [39, 40]. We decided for this proposed classification, since it was previously highlighted in the context of disability evaluation and in social insurance medicine [41]. Moreover we believe it provides a sensible framework that allows comparability of data in the field of VR. This classification system of Geyh et al. [42] seems to be comprehensive and, it was developed using a sound methodology. The groupings were then reviewed for correctness by a second researcher (MS).

2.3.3 Nc-pool

The concepts from the “nc”-pool were checked ifcorrectly labeled as nc or not covered by the ICF. According to the linking recommendations from Cieza et. al. the use of codes ending in “8” should be avoided. Thus nc was assigned instead of using “8”-codes[36, 43]. If the concept was changed from nc to nd, the respective concept was reassigned to the nd-pool.

The analysis of the nc concepts employed a procedure that followed the steps of a conventional quali-tative content analysis. Qualitative content analysis is a method to systematically describe and analyze the meaning of qualitative data [44]. Even though our data was pre-processed during the linking to the ICF, the data is still qualitative in nature. Thus qualitative data analysis remained the methodology of choice.

As suggested by Schreier [38], a coding frame was developed by the first author (MF). This initial coding frame grouped the nc concepts that originated from the expert survey, and common themes (also called dimensions) were generated and defined. If appropriate, themes were broken down into sub-themes. This initial coding frame was reviewed for consistency and content by the research team. In a next step the nc concepts from the systematic literature review and the focus groups were added to the coding frame (MF). In this process, the frame was regularly verified, revised and expanded if new themes developed. During the revision and finalization process, the coding frame was discussed with two additional researchers (MS and RE) and revised accordingly.

Face and content validity of the results were achieved on the basis of the source study data, which were generated based on multiple perspectives i.e. the evidence in the literature, persons engaged in VR, experts, and clinicians in VR. We also undertook a peer-reviewprocess as part of quality assurance of the linking done in the source studies. Moreover, to ensure trustworthiness, we constantly referred back to the raw data of the source studies to verify the correctness of the concept groupings. We have also implemented a structured documentation process of how data was qualitatively analyzed and reviewed.

2.4 Ethics

In this study we reanalyzed data from three previous studies that were approved by the Ethics Commission of Aargau, Lucerne, Zurich, and Wallis in Switzerland and Bavaria in Germany.

3 Results

3.1 Nc Concepts

In the revision of the concepts labeled as nc, 50 concepts were re-assigned as nds, resulting in a final number of 1,093 concepts in the nd-pool. Nd concepts were organized into three theme groups.

The first theme group contains global themes related to the ICF, such as Functioning and Disability. Within the ICF, Functioning and Disability are defined as umbrella terms for the components Body functions, Body structures and Activities and participation. In addition this group of themes encompassed ndconcepts that are too broad to be assigned to one ICF component or category such as symptoms, resources or activities of daily living. (See Table 3)

The second theme group lists nd concepts from the component of Activities and Participation that are so specific that they were able to be transformed into “8” code categories, such as d4308 Lifting and carrying_other specified_lifting overhead or d8508 Remunerative employment_other specified_heavy work. (See Table 4)

Finally, the third theme group included 375 nd concepts that relate to the ICF component of Environmental factors. Most of these concepts appear to be further specifications or supplementary to the Environmental factors chapters, such as the type of housing related to Chapter 1 Products and technology or work-related factors that can be assigned to Chapter 5 Services,systems and policies. Some concepts were even able to be transformed into “8” code categories. (See Table 5)

Regarding the 50 concepts that were redirected to the nd-pool from the nc-pool, 23 categories were assigned to “8” codes, such as d198 Learning and applying knowledge_other specified_preparing for job interview or e498 Attitudes_other specified_ expectations of others.The remaining 22 former nc concepts were assigned to e5 “Work-related factors”. (see Table 5)

3.2 Pf Concepts

1,924 concepts from the pf-pool were linked to 31 second-level categories of the pf classification of Geyh et al. (see Table 6). Table 6 also shows the source study of each pf concept. While categories related to Patterns of feelings (i710) and Patterns of thoughts (i720), such as ways of dealing with conflicts or self-efficacy and self-esteem, were mainly mentioned by health professionals and vocational experts in the expert survey, categories related to Personal preferences (i570), Personal needs (610) and Personal interests (i620) were only targeted in the patient focus groups.

3.3 Nc Concepts

A final number of 441 nc concepts was analyzed and six main themes were defined (see Table 7). The first theme includes concepts related to well-being, such as general well-being and quality of life. The second theme attributes related to processes and time represent a characteristic or inherent part of processes that highlights a specific time frame or point in time. Concepts covered by attributes related to time are essential to describe a trajectory over time or a process, which was based on functioning information that was collected cross-sectionally using the ICF [11]. Theme three refers to threats to safety i.e. factors that may influence how a person behaves with regard to relationships and the environment. Theme four, attributes and actions related to society and social integration, represents characteristics inherent to society as a whole or features of social integration. Theme four also reflects the role played by others, irrespective of impact on the person in question, criminal activities and the criminal background of the person. The latter may have an influence on the interactions between the person and environment. Theme five, intervention approaches and strategies, reflects approaches (i.e. a way of dealing with a situation or problem) and strategies (i.e. plan of action designed to achieve a long-term or overall aim) that external actors often employ to benefit the person engaged in VR. Intervention approaches and strategies applied by others reflect the skills and the knowledge of the person applying the intervention.

Theme six, attributes related to gains and losses due to illness, covered concepts that were attributed to the person who experienced gains and losses attributable to the person’s health condition rather than to any component of the ICF. For this reason, these concepts were considered nc.

4 Discussion

Through an analysis of secondary data this qualitative study explored three types of meaningful concepts within the context of VR that were unable to be linked to distinct ICF categories.

With the development of the ICF Core Set for VR a valuable standard now exists for evaluating and documenting functioning in the context of VR [23, 45]. The results of this study reflect the three perspectives of the source studies. Reflecting the research perspective the systematic literature review investigated previously studied VR outcomes [33]. The expert survey evaluated factors relevant for VR from the expert perspective [32], and the patient focus group study identified factors important to persons participating in VR [31].In our study, we analyzed those concepts that were previously not explored, and by doing so identified aspects not covered by existing ICF categories that could help clinicians and researchers to gain a more complete and comprehensive picture of what to consider in VR. The concepts with no direct link to the distinct ICF categories reveal complementary and essential aspects of functioning and disability that would be important to assess and document when assisting individuals to participate in the working world.

One finding from the analysis of the meaningful concepts in the nd-pool was that experts, questionnairesand patients themselves often use expressions and key terms that are only partially definable by ICF terminology. Familiar ICF terms such as functioning or disability can inform discussion on work disability, but can at times provide insufficient specification of work-related information. In addition, since the ICF describes functioning and disability in terms of Body function, Body structure and Activities and Participation [9], global terms, such as daily activities or homework are not defined as distinct ICF categories themselves, but may be expressed by its underlying Activities and Participation categories, for example d630 Preparing meals, d640 Doing housework, and d650 Caring for household objects for the term ’household chores’. Aligning the discipline-specific terminology with that of the ICF would help to increase awareness about the relationship between these two terminologies and growing acceptance of ICF language.

Fifty meaningful concepts that were identified as nc in the source studies were reassigned to the ICF, taking advantage of the option offered by the ICF to define new categories using an “8”-code, e.g. d198 Learning and applying knowledge, other specified_ acquiring information or d4308 Lifting and carrying, other specified_ lifting objects above shoulder level. While employing this “8”-code option enables users to formulate ICF categories specific to a clinical or research need, comparability of results is only assured when every stakeholder of the user group has agreed on the newly-defined category. In the field of VR, especially when assessing Environmental factors, more detailed and commonly-accepted categories would enhance the precision and comparability of information.

To evaluate the meaningful concepts linked to pf the personal factors classification proposed by Geyh et. al [40, 42] was applied. This classification was based on systematic literature research and was developed for complementary use along with the ICF classification. The primary reason for using this pf classification proposal instead of developing a new coding frame specifically for pf was to enhance future comparability with diverse health conditions or settings e.g. disability evaluation or work capacity evaluation, for which the Geyh et al. personal factor-proposal has recently been used [41]. In our study the personal factor-proposal of Geyh et al. demonstrated to be a valuable reference for grouping and analyzing the meaningful concepts from the pf-pool in the context of VR.

Sociodemographic factors such as educational and occupational background along with life events, medical history and co-morbidities were clearly identified in all three source studies, thus assuming that these factors also reflect the expert, patient and research perspectives. This finding validates the importance of educational and professional qualifications and experiences for successful job performance [46]. Co-morbidity is not only an issue for persons participating in VR [47] it also poses a major challenge to treatment and return-to-work efforts [48, 49]. Understanding of the health condition, and knowledge about VR and labor market services were also found to be relevant in all three source studies; this type of information can be provided to the persons participating in VR and must be taken into account by the VR team [50, 51].

Personal attitudes and beliefs towards the sickness role, fear avoidance, pain and expectations of return-to-work were also mentioned by all three source studies, again reflecting all three perspectives (i.e. expert, patient and research). Interestingly, the same factors have been found to be major predictors for successful return-to-work [52, 53]. Meaningful concepts linked to Personal evaluations (i560) such as satisfaction with life, job and social participation were also confirmed by all three perspectives and reported to be major factors for sustaining work or for a successful return-to-work process [54, 55]. Patterns of thoughts (i720) and Patterns of behavior (i740) mostly referred to thinking and handling strategies applied by patients to cope with their situation. As interventions supporting problem-solving abilities are shown to be effective in preventing work disability, evaluation of coping strategies may be a crucial factor in successful VR programs [56, 57].

In addition to themes supported by all three source studies, Personal preferences (i570), such as having other job alternatives from which to choose or being able to express preferences for specific interventions, was only mentioned by patients. In the whole scheme of patient-centered care, subjective preferences as well as needs and expectations are important factors, and are known to improve rehabilitation outcomes [58 –60]. Hence patient-centered information must be considered when providing VR services.

Complementing the ICF Core Set for VR with a pool of additional themes, that outline other aspects offunctioning that are not directly specified by the ICF, may help to better understand and describe the complexity of functioning of individuals engaged in VR. For example, when designing a new documentation tool to describe functioning that needs to be understood by multiple professionals across diverse settings, the dataset could be based on the ICF Core Set for VR and complemented by “8”-codes of Activities and Participation as well as specific “work-related” terms. In addition the results of this study could help facilitate the selection of relevant personal factors.

Of the six themes derived from the set of meaningful concepts not covered by the ICF model, the first theme was Concepts related to well-being including general well-being and quality of life. In the literature and in clinical practice, well-being and quality of life are often used interchangeably [61]. WHO defines well-being as a term encompassing the total universe of human life domains, including physical, mental and social aspects that make up what can be called a “good life” [62].Quality of life, on the other hand, deals with what people “feel” about their health condition or its consequences. It represents a construct of “subjective well-being” that is in contrast to the ICF, which refers to “objective” description of functioning. In light of this, the concept of functioning and the concept of quality of life complement each other.

The second theme in the nc-pool was attributes related to processes and time (in the work place, health care etc.). This theme recognizes the developmental and temporal character of VR and the fact that the ICF was developed to assess and document human functioning in the context of health and not necessarily to describe trajectory over time or during a process. The process of VR is influenced by many factors. Defining time points, as the start of an intervention, discharge and work resumption and time periods, such as the duration of sick leave, rehabilitation interventions and the time since injury are essential to structure the course of VR. Users of the ICF are therefore explicitly advised to identify their coding rubric and time frame depending on their need i.e. fit-for-purpose [10]. For example when planning a new VR program, selected ICF categories, complemented by work-related factors, pfs and, depending on the rehabilitation goal, factors that are not covered by the ICF, may define the “what” - a checklist of what should be taken into account when performing a comprehensive vocational assessment, goal-setting and an outcome evaluation. In addition a time frame reflecting the rehabilitation process and the “when” also has to be identified. The “when” may include interventions, steering meetings, discharge planning and final evaluation.

This study has several limitations. Our data are limited to information gained from the three source studies. Since the information comes from diverse sources, only qualitative evaluation of the underlying concepts was possible. Although it could be shown from which source study the single concepts were derived, no quantitative inferences could be made. Therefore, the themes identified have to be further tested for prognostic and therapeutic value, or operationalized in an intervention study or clinical trial.

Moreover, when looking at the demographics of the focus group study participants, only a limited number of health conditions and a narrow range of VR interventions were represented despite efforts to ensure heterogeneity to the fullest extent possible.

Only 13% of the meaningful concepts linked to nd, pf and nc in the three source studies (441 out of a total of 3,457), namely the remaining ncs, were unable to be linked to the ICF.

To summarize, four points can be made. First, complementing ICF categories with work-relevant factors is necessary to ensure comprehensiveness and utility in VR in the clinical setting and in research. ICF “8”-code definitions should be developed for a setting or specific VR program. These “8” codes represent needs of clinical practitioners that may inform and possibly influence future refinements of the ICF. Second, the importance of pf in VR has long been acknowledged [52 , 64]. For comparability and comprehensiveness-sake, personal factors should be addressed in a structured way. In our study the pf-classification proposed by Geyh et al. proved to be a valuable system and should be examined empirically. Third, as recommended by WHO, the ICF can be used when designing rehabilitation and to assess and understand functioning in a comprehensive way. The VR process itself should be further specified with aspects of timing, information about task distribution, and involvement of stakeholders in accordance with the needs and goals of a particular return-to-work program. Finally, since well-being, quality of life and functioning are three different concepts, the respective definitions need to be differentiated and depending on the purpose of the data collection, data has to be collected on either only one or on all threeconcepts.

In conclusion the findings of this study further support the position that the ICF model provides a valuable framework for assessing and documenting functioning in VR. While there are some VR-relevant concepts that are unable to be linked to the ICF, this study is a step forward in exploring and examining those concepts.

The findings of this study confirm the complexity of VR in clinical practice and research. The study also highlights concepts that are complementary to theexisting ICF Core Set for VR; these concepts are essential and are supported by evidence in the literature. We recommend further empirical investigation, particularly in the area of intervention trials, in which the concepts identified in this study can be tested for their influence on return-to-work and utility in developing effective VR programs.

Footnotes

Acknowledgments

We are most grateful for the contributions from the members of the ICF unit who provided feedback and their expertise: Carolina Ballert, Christina Bostan, Maren Hopfe and Birgit Prodinger.

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