J Occup Rehabil (2011) 21:147–155

DOI 10.1007/s10926-010-9276-y

An International Expert Survey on Functioning in Vocational

Rehabilitation Using the International Classification
of Functioning, Disability and Health
Reuben Escorpizo • Monika E. Finger •

Andrea Glässel • Alarcos Cieza

Published online: 9 December 2010

Ó Springer Science+Business Media, LLC 2010

Abstract Background Vocational rehabilitation (VR) is a six WHO Regions (Africa, the Americas, Eastern Medi-
key process in work disability (WD) management which terranean, Europe, South-East Asia, and Western Pacific).
aims to engage or re-engage individuals to work and Experts were asked six open-ended questions on factors
employment. The International Classification of Function- that are important in VR. Each question was related to a
ing, Disability and Health (ICF) by the World Health component of the ICF (body functions, body structures,
Organization (WHO) can be interfaced with VR but there activities and, environmental factors, and personal fac-
is a lack of evidence of what ICF contents experts in the tors). Responses were linked to the ICF. Results Using a
field consider. The objective of this study is to survey the modified stratified randomized sampling, 201 experts were
experts in the VR field with regard to what factors are sent the survey and 151 experts responded (75% response
considered important to patients participating in VR using rate). We identified 101 ICF categories: 22 (21.8%) for
the ICF as the language to summarize the results. Methods body functions, 13 (12.9%) for body structures, 36 (35.6%)
An internet-based survey was conducted with experts from for activities and participation, and 30 (29.7%) for envi-
ronmental factors. Conclusions There was a multitude of
ICF functioning domains according to the respondents
R. Escorpizo (&)
M. E. Finger
A. Glässel
A. Cieza which indicates the complexity of VR. This expert survey
Swiss Paraplegic Research (SPF), Guido A. Zäch Str. 4, has provided a list of ICF categories which could be con-
6207 Nottwil, Switzerland
sidered in VR.
e-mail: [email protected]

R. Escorpizo
M. E. Finger
A. Glässel
A. Cieza Keywords ICF
Vocational rehabilitation
Survey

ICF Research Branch of WHO Collaborating Centre Expert
Work
Employment
for the Family of International Classifications in German,
Nottwil, Switzerland

A. Cieza Introduction
ICF Research Branch of WHO Collaborating Centre
for the Family of International Classifications in German,
Work disability (WD) may occur as a result of a health
Munich, Germany
condition or a health-related event and the associated
M. E. Finger burden may be evident at the individual level and the
Rehaklinik Bellikon, Bellikon, Switzerland society level. This burden may appear in the form of
consequences of limited or restricted work participation.
A. Cieza
Institute for Health and Rehabilitation Sciences, Research Unit Vocational rehab (VR) is a key process in WD manage-
for Biopsychosocial Health, Ludwig-Maximilians Universität, ment which aims to engage or re-engage individuals back
Munich, Germany to work and employment and has been documented in the
literature to be effective in addressing WD issues [1–6].
R. Escorpizo
Department of Health Sciences and Health Policy, University The International Classification of Functioning, Dis-
of Lucerne, Nottwil, Switzerland ability and Health [7] is a generic conceptual framework

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and classification system of the World Health Organization systematic review), internet search, professional organiza-
(WHO) that can be actively interfaced with VR or within tions, journal editorial board, informal networks, and peers.
the context of return-to-work, or work participation [8–11]. An expert who was contacted was also asked to name and
As a conceptual model, the ICF recognizes that functioning refer other experts.
and disability is a result of the interaction between com- Recruitment of experts into the ‘‘pool’’ was performed
ponents: body functions (b), body structures (s), activities from March to June 2009. Selection of experts from this
and participation (d), environmental factors (e), and pool who were to complete the survey was done using
personal factors (not coded). As a classification system, the randomized stratified sampling. This sampling method was
ICF can serve as a basis for evaluating the scope and modified so that at least one expert from each country is
complexity of VR services by providing a comprehensive included. This modification was made to ensure that all the
list of functioning domains in the form of alphanumeric countries in the pool are represented.
coded ICF categories that are arranged in a hierarchical
fashion, hence different levels, for each of the ICF cate- Information from the Experts
gories or functioning domains. Below is an illustration of
this categorization: Sociodemographic information was collected from the
sampled experts. Information included country, age, sex,
profession, main field of practice ([50% of the time), years
of experience in VR, whether they are a direct healthcare
ICF component d activities and participation
provider, primary type of patients they deal with, and types
Chapter d4 Mobility
of VR services they are involved with. Experts were also
Second-level category d430 Lifting and carrying objects
asked to self-rate based on an 11-point numerical scale
Third-level category d4300 Lifting regarding their expertise in VR (from 0 = ‘‘No experi-
ence’’ to 10 = ‘‘Excellent experience’’).

Survey Website and Survey Questions

However, there remains a lack of understanding of
functioning within VR in terms of the ICF, despite the need The survey was conducted in English. The initial part of
for VR providers to understand the broad range of func- the survey asked the respondents information on sociode-
tioning factors (instead of being too focused) to improve mographics and their experience in VR. For the main part
work disability outcomes in the clinical setting or com- of the survey, experts were asked with six open-ended
munity-based setting in VR. Therefore, the objective of this questions (see Table 1) to examine which factors they
study is to survey the experts in the VR field regarding consider relevant and important to individuals who par-
what factors are important to individuals participating in ticipate in a VR program. Each question is related to a
VR using the ICF as the language to summarize the results. component of the ICF (body functions, body structures,
activities and participation, environmental factors, and
personal factors). For example, the first question on ‘‘body
Materials and Method and mind’’ is related to the ICF component of body func-
tions. Experts, however, did not see the ICF component
Recruitment of Experts labels embedded in the questions. Blank fields for the
answers were provided after each question and respondents
A survey was conducted over the internet with expert were allowed to provide multiple answers. Answers were
participants from six WHO Regions (Africa, the Americas, not limited in terms of word length although respondents
Eastern Mediterranean, Europe, South-East Asia, and were instructed to be brief and concise and avoid abbre-
Western Pacific). An ‘‘expert’’ was arbitrarily defined to viations and vague technical terms. The expected com-
have at least 2 years of relevant experience (practice, pletion time for the survey was 30 min.
research, or both) in the field of VR, may be a health
professional, and is able to communicate competently in Linking to the ICF
English [12]. A procedure using Secure Sockets Layer,
128-bit encryption technology ensured the security and All responses gathered from the experts were linked to the
privacy of the web-based survey. ICF applying published linking rules [13]. The objective of
Invitations to the experts were sent out via secure the linking process is to be able to translate the concepts
electronic e-mail. E-mail addresses of experts were found in the experts’ responses into the most fitting
obtained from literature search (through a concurrent ICF categories. Two individuals who are trained and

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Table 1 ICF-based questions that the experts were asked. The ICF component indicated within the brackets were not seen by the participants
1. If you think about the body and mind of individuals participating in vocational rehabilitation, list (function) problems that are relevant to
them? (Body functions)
2. If you think about the body parts of individuals participating in vocational rehabilitation, which body parts are their problems? (Body
structures)
3. If you think about the daily life activities and involvement in the society of individuals participating in vocational rehabilitation, what are
their problems? (Activities and participation)
4. If you think about the environment and the living conditions of individuals participating in vocational rehabilitation, what is hindering
(barrier) for them? (Environmental factors—barriers)
5. If you think about the environment and the living conditions of individuals participating in vocational rehabilitation, what is helpful
(facilitator) for them? (Environmental factors—facilitators)
6. If you think about individuals participating in vocational rehabilitation, what personal characteristics are important to the way they handle
their situation? (Personal factors)

experienced in the linking process, independently linked Characteristics of Expert Respondents

the responses. The first linker (L1) linked 100% of the
responses, while the second linker (L2) counter-linked 33% Sociodemographics of the respondents and their self-rating
randomly selected concepts of L1. If there was a dis- of expertise are presented in Table 2. About one-third of
agreement between L1 and L2 with the counter-linked the respondents belonged to the 41–50 year-old age range;
concepts, both tried to resolve the disagreement between nearly half of them were male, a little over a third were
them, otherwise a third person was consulted. from Europe, close to two-thirds of the sample were
The ICF categories that were identified based on the physical and occupational therapists, and most respondents
experts’ responses were listed and a frequency analysis was were engaged in clinical or research work. A majority of
performed. the respondents ([85%) had at least 8 years of experience
in the field of VR and have rated themselves at least 7 out
of 10 in the ‘‘expertise scale’’ of 0–10 with number close to
Reliability of Linking
10 meaning greater expertise. About half of the respon-
dents directly provide healthcare service to patients and
To evaluate the reliability of the linking process, the
close to 65% conducts their work on patients with mus-
overall percentage of agreement was calculated based on
culoskeletal health conditions. Looking at the specific types
the two independent linkage versions. In addition, to
of VR services that the respondents provide or are engaged
examine the extent to which the achieved agreement
with in research, we found a broad variety of those services
exceeds chance, the Kappa coefficient [14] and nonpara-
(Table 2).
metric bootstrapped confidence interval [15, 16] were
calculated. We performed Kappa analysis using SAS
Description of Responses and ICF Categories
software version 9.1 (Copyright Ó 2002–2003 by SAS
Institute Inc., Cary, NC, USA).
Based on the responses generated from the survey, most of
the respondents provided topical words and phrases. Mean
time spent to complete the survey for 128 respondents was
Results 29 min and 30 s (median = 21 min and 22 s). Completion
time for the rest of the experts was excluded because they
Recruitment of Experts either took multiple days or longer than 8 h to complete the
survey. The survey platform was configured to allow them
There were 626 experts recruited into the pool who were to answer parts of the survey in different times. This means
identified from our search and were invited to have their that a respondent may start answering a few questions
names in the pool. Out of the 626 experts, 295 (47%) from today and then complete the survey tomorrow, so that will
47 countries agreed to be in the pool. After a modified indicate more than 24 h of survey completion when in
stratified randomized sampling (profession 9 WHO region reality it was probably just 30 min in total.
9 country), 201 experts were selected to whom the survey One hundred one second-level ICF categories were
was sent. In total, we received responses from 151 experts identified based on the ICF-linked responses of the experts.
(75% response rate). Electronic reminders (i.e. e-mail) Only those that were stated by at least 5% (arbitrary
were sent to the experts twice in regular interval to decision) of the respondents were included. Out of these
encourage participation. 101 categories, 22 (21.8%) were related to body functions

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Table 2 Demographics and VR experience of experts surveyed Table 2 continued

(percentage of n = 151 expert respondents)
Type of VR Workplace accomodation and adaptation (46.8%)
Age (range in years) 41–50 (33.3%) service Patient education (45.7%) Reintegration to previous
51–60 (27.3%) working in job (43.6%)
31–40 (22.2%) Ergonomics (40.4%)
Above 60 (10.1%) Assessment of professional competence/capacity
20–30 (7.1%) (39.4%) Integration or training for a new job
(33.0%)
Sex Male (54%)
Work conditioning (29.8%)
WHO region Europe (35%)
Job placement (26.6%)
The Americas (30%)
Otherd (25.5%)
Western Pacific (27%)
Work hardening (23.4%)
Southeast Asia (4%)
Task simulation (16.0%)
Africa (3%)
a
Eastern Mediterranean (1%) Other: Teaching/education, rehabilitation counselling, massage
therapy, movement science, pedagogy, rehabilitation science, psy-
Profession Physical therapy (30.3%)
chotherapy, rehabilitation psychology, podiatry, sociology, art history
Occupational therapy (29.3%) and geography, ergonomics, health promotion and health education,
Othera (19.2%) public health, labour/health economics, special education
b
Psychology (14.1%) Other: Clinic consultation, medical legal consultation, editorship,
Medicine (9.1%) community rehabilitation consultation, medico-legal private practice,
caregiver and client training, work/home case management
Vocational counselling (9.1%) c
Other: ‘‘Don’t see clients’’, burn, orthopaedics, psychiatry, educa-
Social work (5.1%)
tion, functional cognition, hearing and seeing impairment, develop-
Case management (3.0%) mental disability
Main field ([50% of the time) Clinic (e.g. manages patients, d
Other: Quality assurance, management, job trials, functional capacity
provides direct care) (32.3%) evaluation, injury prevention, ‘‘direct care’’, group therapy, neurolog-
Research (e.g. perform or ical rehabilitation, workplace rules training, role training, workplace
supervise experiments/studies/ behaviour, consultation/supervision, income benefits training, disclo-
trials) (28.3%) sure counselling, collaborative assessment, supported employment,
Education (e.g. academia, litigation, family and employer education, soft tissue manipulation,
faculty, teaching) (21.2%) referral to networks, functional cognition assessment, case manage-
ment, editorship
Management/Business (e.g.
manages clinic, hospital)
(11.1%) (Table 3), 13 (12.9%) were related to body structures
Otherb (7.1%) (Table 4), 36 (35.6%) were related to activities and par-
Years of experience in VR 85% More than 8 years ticipation (Table 5), and 30 (29.7%) were related to envi-
(mean in years)
ronmental factors (Table 6).
Direct involvement with providing Yes (50.5%)
Our reliability calculation between linkers (researchers)
healthcare to VR participants?
at the second-level ICF categories resulted in an overall
Self-rating of expertise in VR C7 out of 10 (78.8%)
percentage agreement of 61.7%, an estimated 0.61 Kappa
Type of patients involved with Musculoskeletal (bone, muscle,
and soft tissues) (64.6%) coefficient, and a confidence interval (bias corrected per-
Neurologic (brain, spinal cord, centile method) of 0.58–0.63. For the third-level catego-
nerves) (44.4%) ries, the overall percentage agreement was 56.0%,
Mental problems (cognition, estimated 0.55 Kappa coefficient, and a confidence interval
psychological) (44.4%) (bias corrected percentile method) of 0.53–0.58.
Othersc (11.1%)
Cardiovascular (heart, blood
vessels) (10.1%) Discussion
Intoxication, substance abuse,
drug addiction (10.1%)
VR is a key process that enables individuals to participate
Respiratory (lungs) (8.1%)
in or return back to gainful employment. VR, as a com-
Internal medicine (endocrine,
ponent of work disability management, covers a wide
cancer, etc.) (5.1%)
variety of factors. In this study, we used the ICF as a
Integumentary (skin) (3.0%)
conceptual framework and classification system to explore

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Table 3 Body functions (N = 22) (included were only those cate- Table 5 Activities and participation (N = 36) (included were only
gories mentioned by at least 5% of the respondents) those categories mentioned by at least 5% of the respondents)
ICF code Title Percentage (%) ICF Title Percentage
code (%)
b126 Temperament and personality function 51.4
b130 Energy and drive functions 50.7 d850 Remunerative employment 35.2
b152 Emotional functions 37.3 d855 Non-renumerative employment 28.1
b164 Higher-level cognitive functions 30.9 d475 Driving 23.9
b730 Muscle power functions 28.1 d920 Recreation and leisure 23.9
b280 Sensations of pain 27.4 d240 Handling stress and other psychological 23.2
demands
b455 Exercise tolerance functions 26.7
d470 Using transportation 22.5
b117 Intellectual functions 25.3
d570 Looking after one’s health 18.3
b140 Attention functions 20.4
d640 Doing housework 18.3
b134 Sleep functions 14.7
d510 Washing oneself 14.7
b122 Global psychosocial function 11.9
d230 Carrying out daily routine 14.1
b180 Experience of self and time functions 11.9
d845 Acquiring, keeping and terminating a job 13.3
b760 Control of voluntary movement functions 11.9
d620 Acquisition of goods and services 12.6
b156 Perceptual functions 9.8
d630 Preparing meals 12.6
b160 Thought functions 9.8
d540 Dressing 11.9
b710 Mobility of joint functions 9.8
d440 Fine hand use 11.2
b144 Memory functions 9.1
d450 Walking 11.2
b167 Mental functions of language 7.7
d520 Caring for body parts 10.5
b210 Seeing functions 7
d410 Changing basic body position 9.8
b230 Hearing functions 7
d430 Lifting and caring objects 9.8
b440 Respiration functions 5.6
d455 Moving around 9.8
b620 Urination functions 5.6
d910 Community life 9.1
d750 Informal social relationships 8.4
Table 4 Body structures (N = 13) (included were only those cate- d760 Family relationships 8.4
gories mentioned by at least 5% of the respondents) d415 Maintaining a body position 7.7
ICF Title Percentage d710 Basic interpersonal interactions 7.7
code (%) d720 Complex interpersonal interactions 7.7
d210 Undertaking a single task 7
s730 Structure of upper extremity 33.8
d660 Assisting others 7
s750 Structure of lower extremity 32.3
d860 Basic economic transactions 7
s760 Structure of trunk 31.6
d170 Writing 6.3
s110 Structure of brain 30.2
d330 Speaking 6.3
s710 Structure of head and neck region 19.0
d350 Conversation 6.3
s720 Structure of shoulder region 17.6
d770 Intimate relationships 6.3
s770 Additional musculoskeletal structures related 14.7
d166 Assisting others 5.6
to movement
d530 Toiletting 5.6
s220 Structure of eyeball 9.8
d740 Formal relationships 5.6
s120 Spinal cord and related structures 9.1
s410 Structure of cardiovascular system 7.7
s250 Structure of middle ear 6.3
factors that need to be considered in VR and linked the
s260 Structure of inner ear 6.3
factors to the ICF so it can be meaningful to ICF users. We
s430 Structure of respiratory system 5.6
found that there is a multitude of ICF functioning domains
based on the experts’ responses which indicates further the
complexity and breadth of VR as a field of research and
and examine factors surrounding VR and this study benefits practice.
from the ICF language and its cross-setting application. We The experts’ perspective has been documented and
conducted a worldwide survey of experts who are involved reported in the literature [17–21]. Information gathered
in VR. We asked questions on what are the important from the experts in the area provides a unique and rich

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Table 6 Environmental factors

ICF Code Title Percentage (%)
(N = 30) (included were only
those categories mentioned by e310 Immediate family 40.8
at least 5% of the respondents)
e580 Health services, systems and policies 38.7
e590 Labour and employment services, systems and policies 37.3
e315 Extended family 36.6
e330 People in positions of authority 26.7
e165 Assets 24.6
e540 Transportation services, systems and policies 23.2
e570 Social security services, systems and policies 23.2
e325 Acquaintances, peers colleagues, neighbours and community members 21.8
e355 Health professionals 20.4
e150 Design, construction and building products and technology for public use 18.3
e155 Design, construction and building products and technology for private use 17.6
e430 Individual attitudes of people in positions of authority 17.6
e135 Products and technology for employment 16.2
e110 Products or substances for personal consumption 15.4
e425 Individual attitudes of acquaintances, peers colleagues, neighbours 15.4
e120 Products and technology for personal indoor and outdoor mobility 14.7
e340 Personal care providers and personal assistants 14.7
e410 Individual attitudes of immediate family members 14
e320 Friends 13.3
e415 Individual attitudes of extended family members 12.6
e550 Legal services, systems and policies 11.9
e460 Societal attitudes 9.9
e585 Education and training services, systems and policies 9.8
e360 Health-related professions 9.1
e115 Products and technology for personal use in daily living 8.4
e575 General social support services, systems and policies 8.4
e450 Individual attitudes of health professionals 7.7
e565 Economic services, systems and policies 7
e525 Housing services, systems and policies 5.6

source of knowledge to understand workers with disability. relative to developing or undeveloped nations. Indeed, VR
This knowledge will further be useful for health care pro- services and its way of delivery vary even among devel-
viders and clinical researchers. oped countries [22, 23] due to difference in system and
The experts who have participated in this survey had politics. The variation between world regions could be
different backgrounds. They came from 47 different associated with variation in the availability of established
countries, a fact which contributed to the multicultural and health, economic, labor, and social systems that may be
multinational perspective. This characteristic would also able to provide vocational rehabilitation services.
have an important implication in terms of possible appli- The respondents had different professions bringing their
cability of this study to other settings. While it is remark- own unique and shared experience either into a unidisci-
able that experts from all six WHO regions participated in plinary or interdisciplinary VR setting. This finding gives
this study, it is interesting to note that most of them came an indication of broad scope of VR given the different
from developed regions such as Europe (primarily Western disciplines to address return to work or increasing work
Europe), the Americas (primarily USA and Canada), and participation. Most of the respondents were therapists
Western Pacific (primarily Australia). There is a great (physical or occupational therapist). However, we learned
imbalance of the number experts from the different regions that different professionals from some countries have dif-
(only 12 out of the 151 experts, were from the WHO ferent scope of practice in providing VR. In South Africa,
regions of Africa, Eastern Mediterranean, and Southeast physical therapists usually do not see patients for VR
Asia). The practice of VR could be more established in but occupational therapists do. A high proportion of
developed nations where VR infrastructure is in place, respondents represented the category ‘‘other professions’’.

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Looking closely at this category provides an insight as to (d850 remunerative employment) being the most frequently
how broad VR practice and research areas are—from mentioned category. Other work-relevant categories were
movement science to sociology, public health, and health d845 acquiring, keeping and terminating a job, d240
economics. Since our recruitment for experts was inclusive handling stress and other psychological demands (perhaps
rather than exclusive, we were not surprised to find a applicable to mental-type of health conditions or jobs that
variety of different fields of VR practice—from experts demand mental competency), and d440 fine hand use and
who directly manage patients to those engaged in clinical d430 lifting and carrying objects (perhaps applicable to
trials, teaching, and management. Given the multidisci- physical-type of health conditions or jobs that demand
plinary practice of VR, it is likely that experts do cross- physical skills). On a different note, non-remunerative
over from one setting to the other within the same period (non-paid) employment categories (d855 non-remunerative
(e.g. treating patients and teaching at a university). employment) such as volunteering were considered
The level of experience of the respondents was important along with d920 recreation and leisure, d640
remarkable—the majority of them have 8 years of experi- doing housework, d230 carrying out daily routine which
ence at a minimum, which gives credible weight to their are not necessarily traditional work domains. This evidence
input on the study. Moreover, a majority of the respondents on work and non-work factors relevant to VR is essential in
rated themselves high in terms of their expertise in the field understanding work disability in general and in the delivery
of VR. Our sample represented a good variety of experts of successful VR [31]. Further, it supports the notion that
who provide direct care to patients and those who work ‘‘employment’’ or work does not necessarily have to be
in research or administration—two perspectives that are paid to be considered as such.
essential. With regard to categories from the component envi-
The health conditions most commonly treated or ronmental factors, it was evident that support from people
researched by our respondents were musculoskeletal, surrounding the worker is essential. This support may come
mental, and neurologic health conditions. This finding is from family members (e310 immediate family, e315
indicative of the high prevalence and great socioeconomic extended family), boss or employer (e330 people in posi-
burden that these health conditions (alone or in coexis- tions of authority), and co-workers (e325 acquaintances,
tence) pose on patient level [24–27]. peers, colleagues, neighbours and community members).
The diverse characteristics of the respondents were also This finding is consistent with the role that support and
evident in terms of the VR services or programs they are relationship play as part of one’s social environment
engaged with. Although the list of VR services was not [8, 34]. The physical and at times political environment
exhaustive, it gave us an indication of the complexity and does play a crucial role in facilitating work participation
breadth of VR. Data on ‘‘other VR services’’ was collected [35–37]. Support from health care services and providers
to ensure that the full spectrum of services possible was (e580 health services, systems and policies and e355 health
covered which provided us additional information on VR professionals), labour services and providers (e590 labour
services such as consultation, caregiver training and work and employment services, systems and policies), and social
and home management. security services and providers (e570 social security
The experts’ perspective based on this survey covered services, systems and policies) was also considered by the
all four classifiable components of the ICF: body functions, respondents to be essential. These services related to
body structures, activities and participation, and environ- health, labour, and social security appear to be the ‘‘tri-
mental factors. Of these components, activities and fecta’’ in facilitating work participation. Within the context
participation represented the most categories followed by of remuneration, assets (e165) in form of money, income,
environmental factors and body functions. The least rep- salary, or benefits could indeed facilitate or sustain return
resentation could be found by body structures categories. to work [8]. Other physical infrastructures were also
This finding signifies a broad societal perspective rather observed such as transportation (e540 transportation
than a sole consideration for the individual structure-level services, systems and policies), building accessibility (e150
alone. This broad representation of the ICF components design, construction and building products and technology
was found to be essential if VR or a return-to-work were to for public use and e155 design, construction and building
be successful [28–31]. products and technology for private use), and the work-
The ICF categories selected based on the expert survey place (e135 products and technology for employment).
is reflective of VR as a multifaceted and multifactorial The categories under the body functions component of
process. Work resumption as a function of work status is a the ICF lend its applicability to different kinds of health
common indicator of VR success [3, 32–34]. In the com- conditions and types of work, either physical or mental, or
ponent activities and participation, therefore, it was not a combination of both. Mental health-related categories
unsurprising to find remunerative or gainful employment that were evident from the experts’ responses include b126

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temperament and personality functions, b164 higher-level for example, only physical therapists are allowed to pro-
cognitive functions, b117 intellectual functions, and b140 vide VR or VR services are provided for physical health
attention functions as examples. Physical health condition- conditions only and not for mental conditions. Fourthly, the
related categories included b730 muscle power functions, type of VR services that the experts were involved with
b760 control of voluntary movement functions, and b710 were not exhaustive. Thus, it is possible that VR encom-
mobility of joint functions, as examples. On one hand, there passes more services than what was given as options in the
might be VR factors that are relevant across health con- questions to the respondents, although the category
ditions but may have varying effects or influence depend- ‘‘Other’’ was provided as a choice. While this is not the
ing on whether it is mental or musculoskeletal condition in main objective of this study, information relating to VR
nature [34]. On the other hand, in some VR participants practices may provide insight to the variety of services
with certain health conditions and job types, both mental provided under VR in different countries and, as such, may
and physical-relevant categories may be applicable. indicate the scope of VR and the professionals who provide
The respondents also included several categories from it. Closely examining the category ‘‘Other’’ revealed some
the body structures component that were important in VR. redundancy with VR services that were already specified.
A few items but a comprehensive list included structures Finally, our study does not provide ways on ‘‘how’’ to
that were relevant to mental, musculoskeletal, and neuro- measure the ICF categories. We feel that this is a critical
logic health conditions that appeared to be consistent with next step if we are to operationalize the ICF categories in
type of health conditions the respondents commonly deal actual VR setting.
with. These structures included brain (s110 structure of
brain), back and extremities (s730 structure of upper
extremity, s750 structure of lower extremity, and s760 Conclusions
structure of trunk). Also included were structures of special
senses such as the eye (s220 structure of eyeball) and ear Our findings support the wide array of factors on func-
(s250 structure of middle ear and s260 structure of inner tioning domains, from the experts’ perspective, that need to
ear). This coverage reflects the broad spectrum of diseases be considered in VR practice and research. This study has
in VR settings that experts encounter. provided us with a list of ICF categories that were con-
We did not make a separate analysis for inter-country sidered to be important in the VR process by expert
or—region difference of responses. We assumed that the respondents and which can help advance our understanding
ICF functioning domains operate regardless of country, of the factors towards successful outcome. We encourage
region, or setting. We suspect, however, that there might be the VR community to further examine the list of variables
variation at the granular level of the systems, politics, provided here. Validation studies are needed in the near
governance, social environment, and services—which future to look at the utility of the categories in interpro-
overall may still be similar in ICF terms but whose oper- fessional communication (i.e. health care providers), ser-
ationalization may be different. Nevertheless, the ‘‘con- vice provision and reimbursement, and health information
ceptualization’’ of the different domains in different record.
countries may not be different, in our opinion.
With regards to our linking methodology, there was not Acknowledgments The authors would like to thank Dr. Teresa
Brinkel, Veronika Lay, Miriam Lückenkemper, Andrea Pfingsten, and
only a satisfactory agreement between the linkers but the Wolfgang Segerer for providing technical consultation and help
agreement also exceeded chance. This shows that the during the conduct of the study. Special thanks to Cristina Bostan,
linking procedure was reliable in this study. who is supported by a Marie Curie Fellowship from the EU funded
We do recognize the limitations of this study. First, the project MURINET, the ICF Research Branch and the Swiss Para-
plegic Research in Nottwil, Switzerland. This project was funded by
results could not be generalizable to all experts’ perspec- the Swiss Accident Insurance Company (SUVA).
tives on VR. While there was high response rate, it is
possible that some experts who have been contacted did not
receive the invitation due to incorrect e-mail addresses, or
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