Advances in Physiotherapy.

2008; 10: 127
137

ORIGINAL ARTICLE

ICF: Clinical relevance for physiotherapy? A critical review

LARA ALLET1, ELISABETH BÜRGE2 & DOMINIQUE MONNIN1

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1
Department of Neuroscience, Geneva University Hospital and University of Geneva, Geneva, Switzerland, and 2Haute Ecole
de Santé Geneva, University of Applied Sciences, Western Switzerland

Abstract
The International Classification of Functioning, Disability and Health (ICF) holds great promise for providing the
rehabilitation disciplines with a universal language. However, the ICF is still highly complex and questions remain about its
practicability. The aims of this review were to (i) identify how the ICF is integrated in the clinical activity of physiotherapists,
(ii) discuss advantages and limits of the use of the ICF, and (iii) suggest further possibilities for implementing the ICF by
physiotherapists. A literature search on Medline, Cochrane, CINAHL and PEDro (key words: ICF, physiotherapy, physical
therapy, clinical application, clinical use) was carried out, together with a check for articles on Google Scholar. Of 155
identified articles, 22 were specific to physiotherapy. These articles described the utility of the ICF to facilitate decision-
Adv Physiother 2008.10:127-137.

making for physiotherapists; to classify the evaluation of therapy outcomes; to ensure that all aspects of human functioning
are represented while testing the effectiveness and the reliability of these outcomes; to structure the documentation of
assessments and interventions, as well as to ameliorate the communication. ICF has a clinical relevance for physiotherapists,
although the limited reliability of the qualifier system for the feasibility of its implementation was shown. The authors
emphasize that the ICF is a tool that facilitates the decision of what to measure but not how to measure.

Key words: Clinic, ICF, physiotherapy

Introduction b28 Sensation of pain (second level);

b2800 Generalized pain (third level);
The International Classification of Functioning,
b28013 Pain in back (fourth level).
Disability and Health (ICF) (1) holds great promise
for providing the rehabilitation disciplines, including
However, it is necessary to add a ‘‘qualifier’’ to
physiotherapy, with a universal language with which
each relevant category code. Qualifiers ensure that
to discuss functioning, disability and related phenom-
the classification
in which domains and codes are
ena (2). The World Health Organization (WHO)
expressed in neutral language
is used meaningfully.
endorsed the ICF in 2001. The ICF is recognized as a
Thus a uniform or ‘‘generic’’ qualifier is provided to
reference member of the WHO family of international
record, on a scale, the extent of the ‘‘problem’’ in
classifications (WHO-FIC), and is complementary to
relation to impairment, activity limitation, participa-
the International Classification of Diseases and Re-
tion restriction and environmental barriers as illu-
lated Health Problems (ICD) (1,3).
strated in this example:
The ICF contains a list of 1454 so-called ‘‘ICF
categories’’, which form the units of the classification
0 No problem
and which are hierarchically organized as shown in
1 Mild problem
the following example:
2 Moderate problem
3 Severe problem
b2 Sensory functions and pain (first/chapter
level); 4 Complete problem

Correspondence: Lara Allet, Service de Physiothérapie, Hôpitaux Universitaires de Genève, 26 Av. de Beau-Séjour, CH-1211 Genève 14, Switzerland.
E-mail: lara.allet@hcuge.ch

(Received 29 January 2008; accepted 16 May 2008)

ISSN 1403-8196 print/ISSN 1651-1948 online # 2008 Informa UK Ltd.
DOI: 10.1080/14038190802315941
 128 L. Allet et al.
8 Not specified
9 Not applicable
The use of this universal language in a multi-
disciplinary team should enhance communication
and stimulate multidisciplinary practice and research
(4). However, many physiotherapists have yet to
integrate the ICF into a clinical workday. The first
step for its implementation was the development of
the core sets (5
24). Each core set contains ICF
categories relevant to diseases belonging to one of the
following medical domains: neurology, musculoske-
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letal and internal medicine. These categories provide
a useful basis for structuring multi-professional
patient care. After the elaboration of these multi-
disciplinary core sets, physiotherapists expressed a
desire to apply them to rehabilitation (25
27).
Physiotherapists thus suggested incorporating the
ICF into their documentation, featuring patients’
impairments under ‘‘body functions and structures’’,
limitations under ‘‘activities’’, and restrictions under
‘‘participation’’ (27
31,32). The ICF was subse-
quently described as a tool that facilitates patient
Adv Physiother 2008.10:127-137.
management by serving as a reference for the
documentation of physiotherapeutic examination,
evaluation, diagnosis, prognosis and intervention
(33), all five activities that form the basis of func-
tional diagnosis.
With its components: ‘‘body functions and struc-
tures’’ and ‘‘activities and participation’’, the ICF
classification indeed reflects the core of physiother-
apy practice. Physiotherapists aim to improve func-
tioning and prevent disability not only in
rehabilitation, but also in intensive care and general
wards in acute hospitals and in the community (28).
The ICF is based on an integrative bio-psychosocial
model of functioning, disability and health. It offers
a new approach compared with the current, widely
used one in physiotherapy, based on disability
models such as the Guide to Physical Therapist
Practice (29) or the so-called Nagi model (2,30).
However, in spite of physiotherapists’ suggestions on
how to incorporate the ICF into their documenta-
tion (25
27), the ICF classification is still highly
complex for daily use. Questions remain about its
practicability in a clinical routine. In order to
facilitate ICF use and to structure future research,
it seems appropriate to provide an overview of
different existing experiences about implementation
and to spot where further investigations are needed.
The overall purpose of this critical review was to
summarize information about the clinical applica-
tion of the ICF in physiotherapists’ daily practice.
Specific aims are to (i) identify how the ICF is
integrated into physiotherapists’ clinical activity, (ii)
discuss advantages and limits of the use of the ICF,
and (iii) suggest further possibilities for implement-
ing the ICF for physiotherapists.
Method
Literature search
We conducted a literature search on Medline,
Cochrane, CINAHL and PEDro with the following
strategy: ‘‘ICF AND (physiotherapy OR physical
therapy OR clinical application OR clinical use)’’.
The literature search was limited from May 2001,
the date of publication of the ICF, to 1 November
2007, and key words had to be mentioned in the title
or abstract.
Check for inclusion and exclusion criteria in two steps
(Figure 1)
We checked the inclusion criteria of all found articles
in two steps.
A first step was based on the title and the article’s
general information. For inclusion, the article had to
be written in English, German or French. The key
word ‘‘ICF’’ had to refer to the Classification of
Functioning Disability and Health.
In a second step, two independent reviewers (LA
and EB), read the abstracts of all remaining articles.
If no abstract was available, we read the full text
article. Duplicates and articles in which ICF was not
the main topic but only used as a citation were
excluded.
Complementary information on Google Scholar
We also checked Google Scholar to ensure the
integration of clinical work, specific to physiother-
apy. In order to obtain only specific physiotherapeu-
tic clinical applications of the ICF, we used the
following key words composition for the Google
search: (i) ICF, physiotherapy, clinical application
and (ii) ICF, physiotherapy, clinical use. We inte-
grated full text articles, but excluded for practical
reasons short communications, congress papers or
guidelines in which ICF was mentioned but no
information about its development and concrete
use was available.
Specific to physiotherapy
At the end, we identified all articles that had the
words ‘‘physiotherapy’’ or ‘‘physical therapy ‘‘in the
title or abstract. These articles were read entirely to
determine how the ICF has been implemented and
to examine the documented benefits and limitations.
 ICF and physiotherapy 129

Database: Medline, Cochrane, CINAHL

and PEDro

Key words: ICF AND (Physiotherapy OR

Physiotherapy OR clinical application OR
clinical use)

MEDLINE: 170 Based on Title Based on

Failed topic: 52 Abstract 106
Exclude
Language: 02 Not main topic: 10
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Failed topic: 3
CINAHL: 59 Based on
Language: 1
Exclude Abstract
Duplicates: 18 34
3

PEDRO: 2 Failed topic: Based on

Exclude Language: Abstract
0
Duplicates: 2

COCHRANE: 4 Failed topic: Based on

Exclude
Language: Abstract
2
Duplicates: Not main topic: 02
Adv Physiother 2008.10:127-137.

Interesting articles
on Google : 23 Exclude
Failed topic: 8 Based on
Language: 0 Abstract 12
Duplicates: 3

Total included articles: 154

Specific to physiotherapy: 22

Figure 1. Search strategy.

Results All remaining articles were attributed by both

The literature search identified a total of 235 articles:
170 articles on Medline, 59 on CINAHL, three on
Cochrane and two on PEDro. Eighteen of those
found on CINAHL and the two articles on PEDro
were already identified on Medline. Of the remaining
215 articles, 55 failed to match the topic and three
were excluded, as they were not written in French,
German or English. After the abstract reading of these
157 articles, 15 more articles were excluded as the
ICF was not the main topic but only used as a citation.
To the remaining 142 articles, we added 23 articles
identified on Google Scholar. Of these, we excluded
eight because they did not develop the topic (pre-
sentation, summaries of courses or congress docu-
mentation) and three other articles, which were
identified as duplicates. In total, 12 articles were
added to the 142 and we ended up with 154 articles.
independent abstract reviewers (LA and EB) to
clinical application fields, namely ‘‘communication’’,
‘‘assessment and/or intervention’’, ‘‘outcome’’,
‘‘guidelines’’ or ‘‘basic information’’. All articles
were attributed to one of the following health
domains: ‘‘neurology’’, ‘‘musculoskeletal’’, ‘‘internal
medicine’’ or ‘‘paediatrics’’. In case of disagreement
between the two reviewers (LA and EB), a third
reviewer (DM) made the final decision.
Attribution to the ‘‘communication’’ field was
made if the article was about exchange of information
in an interdisciplinary team, about documentation or
about databases for the exploration of information.
We attributed to ‘‘assessment/intervention’’ all arti-
cles studying assessment or assessment- based inter-
vention strategies, and to ‘‘outcome’’ articles in
which ICF was used to describe treatment results.
Articles concerned with guideline development were
 130 L. Allet et al.
attributed to ‘‘guidelines’’, and articles about the
development of ICF or ICF’s specific tools such as
the core set development were classified as ‘‘basic
information’’. We took pains to attribute all articles to
one of the four health conditions. Each article could
figure in only one clinical application field and under
one health condition. For example, if an article
investigated the general application of ICF to assess-
ment, it was not attributed to a specific health
condition. If a health condition was not obvious, we
checked the ICD (3). For instance, articles concern-
ing fatigue or psychiatry were attributed to ‘‘neurol-
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ogy’’. We also chose to attribute articles on geriatrics
to the health condition ‘‘internal medicine’’.
Of the 154 remaining articles, 72 were attributed
to the clinical application field ‘‘basic information’’,
20 were attributed to ‘‘communication’’, 38 to
‘‘assessment/intervention’’, 2 to the clinical applica-
tion field ‘‘guidelines’’ and 22 to ‘‘outcome’’.
A majority of articles concerned the musculoske-
letal domain (n 42), followed by neurology (n 28)
and then internal medicine (n 27). For paediatrics,
20 articles could be identified. Thirty-seven articles
Adv Physiother 2008.10:127-137.
could not be attributed to any specific health condi-
tion, as they discussed a general application, not
specific to any health condition.
Table I presents all identified articles with their
attribution to the relevant clinical application fields
and medical domains.
Of all identified articles, 22 were specific to
physiotherapy. Of these 22 articles, six (2,33
37)
discussed ‘‘basic information’’, eight (26,27,31,32,38

41) assessment/intervention, three ‘‘communica-
tion’’ (42
44), four ‘‘outcomes’’ (45
48) and only
one (49) concerned clinical guidelines. Seven articles
were attributed specifically to neurology, four to the
musculoskeletal system, three to paediatrics and two
to internal medicine.
The following paragraph describes how the differ-
ent authors tried to integrate the ICF into their daily
practice. We structured the authors’ conclusions
according to the previously stated application fields.
Several authors provided basic information; others
tested the ICF’s reliability. Other articles considered
ways of using the ICF to document assessment and
interventions, improve communication, structure
outcomes and/or guide decision-making.
ICF and basic information. Jette (2) provided an
update on the changing language of disability and
compared the ICF with the Nagi model (3,30). He
stated that the ICF has the potential of becoming a
standard language with which to describe disability,
and look beyond disease to focus on how people live
with their conditions. Dröge & Koerdt (37) took a
similar stand and emphasized the importance of
using a bio-psychosocial approach such as the ICF
for the treatment of low back pain, as pain is not only
a simple sensation but a conjunction of psychological
and social factors. Most importantly, the ICF has
been shown to be adapted to the clinic as a
classification system for physiotherapeutic diag-
noses, treatment goals, interventions, or outcomes
(33). For example, an article studying the use of the
ICF in paediatric physiotherapy (36) described the
application of the enablement framework to develop
meaningful goals and interventions focused on en-
hancing the child’s participation in desired activities.
Two authors were interested in validity and
reliability (34,38). Grill et al. (34) discussed the
reliability of the ICF qualifiers. They assigned
clinically meaningful qualifiers to a specific second
level ICF category and assessed the observer agree-
ment. Their results showed a moderate agreement
between two observers. However, they warned read-
ers that different hierarchical log-linear models
indicated that the strength of agreement was not
homogenous (34). Kirchberger et al. (35) investi-
gated the validity of the ICF core sets for rheumatoid
arthritis from a physiotherapist’s perspective. They
stated that the validity of the core set was largely
supported but that some categories currently not
covered will need further investigation.
ICF and assessment and/or intervention. Four articles
(26,27,31,32) considered ways of using the ICF to
document the assessment and interventions realized
in a physiotherapist’s daily practice. Basing them-
selves on physiotherapists’ clinical records, these
authors developed nine lists with intervention cate-
gories: three lists for each health condition (muscu-
loskeletal, neurology, and internal medicine), and
one per context (acute, rehabilitation and long-
term). These lists can be used to document assessed
and treated cases.
Further possibilities of how to use the ICF to
guide assessment or intervention were shown by
Paltamaa et al. (38), Vaarbakken & Lunggren (41),
Roaldson et al. (39) and Thieme (40); Paltamaa
et al. (38) used the ICF to select relevant ICF areas
to guide assessment in ambulatory multiple sclerosis
patients. They chose various tests and attributed
them to 10 different ICF categories. Investigators
attributed for example the tests: ‘‘timed 10 meter
gait with temporal parameters’’ and the ‘‘6 minutes
walking test distance’’ to the ICF category ‘‘walk-
ing’’. The ‘‘modified Ashworth scale’’ featured in the
‘‘muscle tone function’’ category. This study showed
that primary measures used in rehabilitation are
generally drawn from different domains of the ICF,
 ICF and physiotherapy 131
a
Table I. Articles that were integrated in the critical review.

Article information Application field Health condition

Ref. Title Authors Journal C A/I O G BI Neu MSK Int. Med. Ped

45 Exercise therapy and other types of Cup et al. Arch Phys Med 1 1
physiotherapy for patients with Rehabil, 2007
neuromuscular diseases:
A systematic review
43 Transparency and tuning of Siebes Dev Neurorehabil, 1 1
rehabilitation care for children et al. 2007
with cerebral palsy: A multiple
case study in five children with
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complex needs
35 Validation of the comprehensive Kirchberger Phys Ther, 2007 1 1
international classification of et al.
functioning, disability and health
core set for rheumatoid arthritis:
The perspective of physiotherapists
39 Functional ability in female leg Roaldsen Physiother Res 1 1
ulcer patients
A challenge for et al. Int, 2006
physiotherapy
34 Assessing observer agreement Grill et al J Rehabil Med, 1
when describing and classifying 2007
functioning with the International
Classification of Functioning,
Disability and Health
Adv Physiother 2008.10:127-137.

42 A collaborative model of service Palisano Phys Ther, 2006 1 1

delivery for children with movement
disorders: A framework for evidence-
based decision making
26 Identification of intervention Finger Phys Ther, 2006 1
categories for physiotherapy, based et al.
on the international classification
of functioning, disability and health:
A Delphi exercise
2 Toward a common language for Jette Phys Ther, 2006 1
function, disability, and health
36 Enhancing participation for children Goldstein Pediatr Phys Ther, 1 1
with disabilities: Application of the et al. 2004
ICF enablement framework to
paediatric physiotherapist practice
44 Use of the ICF model as a clinical Steiner et al. Phys Ther, 2002 1
problem-solving tool in physiotherapy
and rehabilitation medicine
41 Superior effect of forceful compared Vaarbakken Adv Physiother, 1 1
with standard traction mobilizations & Ljunggren 2007
in hip disability?
49 The development of a clinical practice van Peppen Disabil Rehabil, 1 1
stroke guideline for physiotherapists in et al. 2007
The Netherlands: A systematic review
of available evidence
47 Outcomes of physical therapy, speech Morris et al. Neurorehabil 1 1
pathology, and occupational therapy Neural Repair,
for people with motor neuron disease: 2006
A systematic review
37 The placebo effect in physiotherapy Dröge & Krankengymnas- 1
for low back pain: A confounder in Koerdt tik, 2006
effectiveness studies (part 2) [German]
48 Use of questionnaire-based outcomes French Phys-Ther-Rev, 1 1
for the measurement of activities and 2006;
participation in the physiotherapy
management of hip osteoarthritis:
A review
40 Scales and tests in Parkinson’s disease Thieme Krankengymnas- 1 1
[German] tik, 2006
 132 L. Allet et al.
Table I (Continued)
Article information
Ref. Title Authors
38 Reliability of physical functioning Paltamaa
measures in ambulatory subjects et al.
with MS
46 Outcome measures to quantify the Freeman
effects of physiotherapy for people et al.
with multiple sclerosis
31 ICF Interventionskategorien für die Allet et al.
Physiotherapie bei muskuloskelettalen
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Gesundheitsstörungen
27 ICF Interventionskategorien für die Bürge et al.
Physiotherapie bei internistischen
Gesundheitsstörungen
32 ICF Interventionskategorien für die Finger et al. Physio Science
Physiotherapie bei neurologischen
Gesundheitsstörungen
33 Umsetzung der ICF in den Huber et al. Physio Science
klinischen Alltag der Physiotherapie
Total
a
All articles considered for this review were attributed to a clinical application field and a health condition. Table I shows for each article its
attributed application field (C, A/I, O, G, B) and health condition. C, communication; A/I, assessment and/or intervention; O, outcome; G,
guidelines; BI, basic information; Neuro, neurology; MSK, musculoskeletal; Int. Med, internal medicine; Ped, paediatrics.
Adv Physiother 2008.10:127-137.
but that one test can be related to several ICF
categories. Another article (41) documented the use
of the ICF to define hip disability. Patients’ impair-
ments included pain, stiffness and decreased joint
mobility, which were considered part of the health
domain ‘‘body functions’’. Roaldsen et al. (39) used
the ICF to describe and quantify disease conse-
quences in elderly females with chronic leg ulcera-
tion compared with an age-matched healthy group.
Their results should provide a background for future
physiotherapy interventions using the ICF as a
conceptual model. The assessment was classified
according to the ICF as shown in the following
example: pain was considered ‘‘impairment of body
functions’’; walking was classified as a ‘‘limitation in
activity’’ and as a ‘‘restriction in participation’’, and
‘‘contextual factors’’ included the use of walking
aids. Thieme (40) classified frequently used assess-
ment tools when treating patients with Parkinson’s
disease into the three main ICF components: ‘‘body
functions’’, ‘‘body structures’’ and ‘‘activity and
participation’’.
ICF and communication. Steiner et al. (44) consid-
ered creating a documentation form similar to the
ICF model to be used for interdisciplinary meetings,
for a common understanding of the patient and for
defining intervention goals. Moreover, they sug-
gested adding qualifiers to environmental factors to
denote them as either barriers or facilitators. Pali-
sano (42) used the ICF as a collaborative model of
Application field Health condition
Journal C A/I O G BI Neu MSK Int. Med. Ped
Physiother Res int 1 1
2005
Neurol Rep 2002 1 1
Physio Science 1 1
2007
Physio Science 1 1
2007
1 1
2007
1
2007
3 8 4 1 6 7 4 2 3
service delivery for children with movement disor-
ders. He applied the ICF to identify relationships
among the components of functioning, environmen-
tal and personal factors that are important for the
care-plan and the achievement of outcomes. The
way the child’s and its family’s priorities change over
time are illustrated in a longitudinal case report of a
child with cerebral palsy. An assumption of the
model is that physical therapists use multiple types
of evidence to guide decision-making. Siebes et al.
documented similar use of ICF (43). They inte-
grated the ICF to promote communication between
health professionals, children and their families.
Authors categorized parent-identified problems,
treatment goals and treatment activities based on
the ICF and analysed their relation to one another.
The rehabilitation process was judged to be ‘‘tuned’’
when a parent-identified problem, a treatment goal
and a treatment activity were linked to the same ICF
code.
ICF and outcomes. Several authors used the ICF in
relation with outcome measures: Morris et al. (47)
summarized common impairments, activity limita-
tions and participation restrictions that are encoun-
tered by patients with motor neuron disease. The
outcome measures were categorized according to the
ICF and the principles of management were related
to the ICF taking into consideration the perspectives
of physiotherapists, speech and occupational thera-
pists. Cup et al. (45) used the ICF to divide outcome

variables in the two categories ‘‘level of body func-
tions’’ and ‘‘ level of activities and participation’’.
The ICF ‘‘activity and participation’’ components
presented as fundamental elements of the assess-
ment of patients with hip osteoarthritis, although
usually under-utilized in physiotherapy (48). These
authors recommend using the ICF to guide decision-
making and ensure that all aspects of human
functioning are represented while testing treatment
effectiveness. Freeman et al. (46), investigating the
ICF application with patients suffering from multi-
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ple sclerosis, also highlighted the part it played in
providing a conceptual framework for the classifica-
tion and evaluation of therapy outcomes.
ICF and guidelines. Only one article used the ICF in a
guideline context. In the first stroke guidelines for
physiotherapists (49), the recommended outcome
measures were classified according to the ‘‘body
functions and activities’’ components.
Adv Physiother 2008.10:127-137.
Discussion
This critical review aimed to summarize information
about the clinical application of the ICF in phy-
siotherapists’ daily practice. Of 154 articles, 21 were
specific to physiotherapy. These articles covered not
only ‘‘basic information’’ but also specific applica-
tions (assessment/intervention, communication, out-
come and guidelines) of the ICF. This paper also
shows that physiotherapists have already started
implementing ICF in their practice, and that its
application in a daily routine is feasible.
The following sections summarize and discuss the
advantages and limitations specific to the ICF, as
described in the articles reviewed.
Basic information
General advantages, especially relevant for interdis-
ciplinarity, have been described in the articles
attributed to ‘‘basic information’’. The ICF provides
a universal and standardized language, which is also
comprehensible for patients (33). It offers a frame-
work regarding disability that goes beyond mere
disease (35)
the possibility to medically classify
functioning without being a psychometrically sound
measure (34). The ICF promises the opportunity to
compare collected data (33,37). It has been said to
facilitate scholarly discussion across disciplines and
national boundaries; it should stimulate interdisci-
plinary research, improve clinical care and ultimately
better inform health policy and management (2,33).
However, the real usefulness of the ICF in the clinic
ICF and physiotherapy 133
and for research remains largely dependent on its
internal coherence (2).
Assessment/intervention
Concerning the application field ‘‘assessment/inter-
vention’’, the ICF is said to make clear at which level
physiotherapy interventions are supposed to induce
change. The ICF has been described as an interest-
ing and relevant means of structuring assessments
and interventions. For instance, the so-called ‘‘lists
of intervention categories for physiotherapists’’
(26,27,31) provide a detailed description as to how
to integrate the classification in a physiotherapist’s
daily routine. These lists (26,27,31) feature cate-
gories that facilitate the understanding of patients’
functional potential not only from a therapeutic, but
also from a patient- and family-centred perspective.
They also help comply with administrative demands
for transparency. In line with the authors who
developed these lists (26,27,31), Siebes et al. (43)
underlined that the ICF is a valuable tool enabling
the thorough documentation
incorporating all
parties’ points of view
which is necessary to subtly
identify the patient’s problems, and then fine-tune
treatment goals and interventions. However, one
difficulty mentioned was the practicality of such a
tool. (26,27,31) The lists should contain relevant
categories, but not too many, in order to limit the
time necessary for completing the assessment pro-
cedure (27,31). Furthermore, informal clinical ap-
plication of these lists showed that their correct use
requires preliminary training (27,31).
Communication
The ICF’s impact as an instrument to improve
communication among health professionals, patients
and their families is another one of its strengths (42

44). The experiences documented in these studies
clearly demonstrated how the relationship between
treatment goals, treatment activities and the pa-
tients’ perceived problems can be concretely pre-
sented. The rehabilitation process thus becomes
explicit to all and communication among therapists,
patients and their families can be optimized.
ICF and outcomes
All articles describing the ICF, when applied to
outcomes, highlighted its importance as a concep-
tual framework for the classification and evaluation
of therapy issues. The ICF was also said to outline
for clinicians and researchers a selection of assess-
ment and outcome measures based on body func-
tions, activities and environmental factors. In this
 134 L. Allet et al.
application field, no specific limitations were dis-
cussed.
Guideline
In this application field, van Peppen et al. (49)
showed that the different outcome measures applied
to individuals who have suffered a stroke measure
the components ‘‘body function’’ (muscle strength
and balance) and ‘‘activity and participation’’ (walk-
ing, hand and arm use and ADL). These authors
observed that most of the recommendations in-
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cluded in guidelines came from studies of post-acute
or chronic stroke patients. However, more needs to
be learned about patients with complex needs. The
observations of van Peppen et al. (49) are in line with
the results of the study by Finger et al. (26), who
investigated ICF intervention categories considered
relevant by physiotherapists treating patients with
neurological conditions. The most frequently named
interventions concerned again ‘‘body functions’’ and
‘‘activities and participation’’.
Adv Physiother 2008.10:127-137.
General discussion
The studies showed in particular examples of how
the ICF could improve the structure of assessments
and interventions. They also described how the ICF
guides decision-making, enhances communication
and contributes to guideline development. The
importance of the ICF for the creation of compar-
able data collections (on a national and international
basis as well as on a disciplinary and interdisciplinary
basis) was another interesting observation.
Regarding the advantages and difficulties men-
tioned previously, we wish to emphasize that the ICF
mainly clarifies the choice of what should be assessed,
thereby guiding the selection of appropriate measure-
ment tools. However, it does not give indications as
to how the condition should be assessed. Further-
more, thorough assessment requires validated mea-
sures. Because of this, although qualifiers could help
implement the use of the ICF in assessment, their yet
limited reliability was identified as one of ICF’s major
limitations (34,44,50).
Our clinical, managerial and educational experi-
ence encourages us to recommend the use of the ICF
for documenting physiotherapists’ interventions. The
lists of intervention categories (26,27,31) or the
general application of the ICF to assessment have
the merit of being integrated in physiotherapists’
daily practice, for the reasons mentioned above.
However, if a physiotherapist wishes to use these
tools efficiently, he/she needs to have a good prior
knowledge of the ICF, its structure and terminology
as well as the capacity to describe clinical situations
from patients’ and health professionals’ perspectives.
Therapists should also analyse the planned interven-
tions according to their underlying goals. Perhaps
this explains why only a few institutions integrate the
complex tools that are entirely based on the ICF. In
Switzerland, only one such a global assessment form
is currently used in clinical practice. It was developed
by the Swiss Interest Group for Physiotherapy in
Neurorehabilitation (51), but is again based on
experts’ consensus and does not provide a reliable
qualifier measurement system.
An informal meeting of physiotherapy teachers
from different countries and continents during the
World Confederation of Physiotherapy congress
(WCPT) in Vancouver in June 2007 showed that
the ICF has been integrated into physiotherapy
education for several years. However, the present
review was unable to find research papers discussing
the use of the ICF in physiotherapy education, in
contrast to nursing. For instance, the integration of
ICF components in undergraduate nursing students’
patient assessments has already been analysed. Pryor
et al. (52) stated that nursing students documented
information about each of the five domains of the
ICF. In their conclusion, the authors expressed the
need for further research, exploring to what extent
the ICF fits into the holistic approach of nursing
practice. These observations underline that research
about the ICF’s advantages and limits in physiother-
apy education should be thought of as a challenge.
Limitations of our article
Because of our intention to provide a complete
summary of the work concerning the ICF and
physiotherapy, we included all the articles that could
be identified with our search strategy without any
exclusions on the basis of methodological quality.
Nevertheless, we summarized the study type, which
provides an informative basis of the articles’ quality
(Table II). We identified three systematic review
articles (45,47,49), one randomized controlled trial
(41), three cross-sectional survey (26,34,35), three
retrospective cross-sectional studies (27,31,32), se-
ven reports (2,33,36,37,40,46,48), one cohort study
(39), one study with repeated measure design (38)
and three case studies (42,43,44). This shows that
only one experimental study provided information
about the topic ‘‘ICF and its integration in a daily
activity of physiotherapists’’. As we had to deal with
a variety of study types, a validated quality assess-
ment was impossible. Therefore, as suggested by the
Berkley Systematic Reviews Group (53), we simply
used the approach of using individual components
figuring on an existing checklist. Articles could only
be checked for four common items following Deeks’
 ICF and physiotherapy 135
Table II. Identification of study type and quality assessment.

Provision of Problem/ Definition of Interpretation

background question study appropriately
Ref. Study type information clearly stated population based on results

45 Cup et al. Systematic review Y Y Y Y

43 Siebes et al. Multiple case study Y Y Y Y
35 Kirchberger et al. Cross-sectional survey (Delphi Y Y Y Y
exercice)
39 Roaldsen et al. Prospective cohort study Y Y Y Y
34 Grill et al Cross-sectional survey Y Y Y Y
42 Palisano Longitudinal case report Y Y Y Y
26 Finger et al. A consensus-building, 3-round, Y Y Y Y
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electronic-mail survey
2 Jette Report of actual situation Y Y NA NA
36 Goldstein et al. Report Y Y NA NA
44 Steiner et al. Case report Y Y Y Y
41 Vaarbakken & Block randomized controlled trial Y Y Y Y
Lunggren
39 van Peppen et al. Systematic review of articles and Y Y Y Y
conference abstracts
47 Morris et al. Systematic review of articles and Y Y Y Y
conference abstracts
37 Dröge & Koerdt Report Y N NA NA
48 French Report Y Y NA NA
40 Thieme Report Y N NA NA
38 Paltamaa et al. Repeated measure design Y Y Y Y
Adv Physiother 2008.10:127-137.

46 Freeman et al Report Y Y N NA
31 Allet et al. Retrospective cross-sectional study Y Y Y Y
27 Bürge et al. Retrospective cross-sectional study Y Y Y Y
32 Finger et al. Retrospective cross-sectional study Y Y Y Y
33 Huber et al. Report of actual situation Y Y NA NA

Y, yes the criterion is fulfilled; N, no the article does not fulfil the criterion; NA, the criterion is not applicable.

list of quality assessment of non-randomized studies Conclusion and recommendations

(54). Although the study designs themselves indicate
only a fair quality of the reviewed articles, most of
them fulfilled our quality criteria. Nevertheless, the
topic itself, namely, ‘‘ICF and its clinical applica-
tion’’ should now be investigated with experimental
studies.
In addition, we admit that we did not check
references mentioned in the identified articles, there-
fore we cannot guarantee an exhaustive summary.
We also encountered difficulties during the attribu-
tion of the articles to the application fields. The
attribution to only one field was not always self-
evident. Although some articles could have been
attributed to more than one application field, each
publication could only belong to one category.
Attribution to a health condition was sometimes
problematic. Geriatrics, for example, was attributed
to ‘‘internal medicine’’, without really knowing
patients’ health conditions. Nonetheless, this review
summarizes articles treating the topic ‘‘ICF and
physiotherapy’’ and provides an overview on already
existing implementations. It also suggests new direc-
tions for further investigation regarding the integra-
tion of the ICF in professional practice.
The overall purpose of this critical review was to
summarize information about the application of the
ICF in physiotherapists’ daily practice. We aimed to
identify how the ICF is integrated in physiotherapists’
clinical activity and we discuss its advantages and
limits. This review has convinced us that the ICF does
have a clinical relevance for physiotherapists with
regards to its different application fields (commu-
nication, assessment /intervention, outcome, guide-
lines). Clinical examples, such as the Classification of
Physiotherapy Interventions, have shown the feasi-
bility of its implementation in a standardized lan-
guage, which promotes communication with other
health professionals, patients and their families.
However, we also identified articles describing the
ICF’s limitations and difficulties in the clinic. The
ICF is a tool that facilitates decision-making about
what to measure and that consequently helps to select
appropriate measurement instruments. However, the
ICF does not indicate how to measure. Concerning
the qualifier system, further investigations are
needed. We observed that little was described regard-
ing the use of the ICF for educational purposes as well
as for guideline development. In order to achieve an
 136 L. Allet et al.
exhaustive implementation, these aspects should be
part of further investigations.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are respon-
sible for the content and writing of the paper.
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