The International Classification of Functioning, Disability and Health (ICF) provides a framework and common language for describing and understanding health that incorporates function and disability, as well as contextual factors. However, whether the meaningful patient outcomes reported by collegiate athletes who have sustained a lower extremity (LE) injury correspond to the ICF model is uncertain.
To determine if the patient outcomes reported by collegiate athletes after LE injury corresponded with the ICF classification and to identify the most relevant ICF categories and domains.
Themes and subthemes from the qualitative analysis were linked to the ICF using established linking rules. The frequencies of the linked ICF categories were identified.
University laboratory.
Twenty collegiate athletes (10 men, 10 women; age = 20.1 ± 1.83 years) from a National Collegiate Athletic Association Division I institution in the Midwest who had sustained an LE injury.
Semistructured face-to-face interviews and ICF linking process.
The data from the qualitative interviews were successfully linked to 63 ICF second-level domains (eg, moving around, d455) across all 4 ICF categories: body functions (b), body structures (s), activities and participation (d), and environmental factors (e). The 63 second-level domains corresponded with 20 first-level domains (eg, mobility, d4).
The ICF provided a common language for describing health and disability, as all outcomes reported by our collegiate athletes after LE injury were linked with the ICF classification. Athletic trainers should use the results of this study for assessing and monitoring collegiate athletes' health and function after an LE injury.
The characteristics of health and function described by collegiate athletes recovering from lower extremity injuries matched the standard language of the International Classification of Functioning, Disability and Health (ICF).
The meaningful outcomes described by participants were linked to 63 ICF second-level domains and 20 corresponding first-level domains across all 4 ICF categories.
It appears the ICF can serve as a universal standard for identifying and assessing impairments, limitations, and restrictions in athletic training patients recovering from lower extremity injury.
The athletic patient population has been deemed unique in that it typically represents higher levels of physical abilities than those of the general population.1 In addition to exhibiting higher levels of physical abilities, psychological and social well-being elements have also been uniquely categorized by these patients.2 Whereas the general population may view their level of health in terms of their ability to complete everyday activities, such as dressing, walking, climbing stairs, and driving, the athletic population may determine their level of health from an athletic perspective. Optimal health for the athletic patient population often includes the ability to perform highly demanding athletic skills, such as cutting, sprinting, and quickly changing directions.3 Thus, many common patient-reported outcome instruments used to measure health fail to capture the athletic patient population's high-level abilities. Because of a ceiling effect, his or her health status as reflected by these instruments may not be accurate, offering less value to the patient or clinician.4 Furthermore, for outcomes assessment to have practical value in a health care discipline and improve patient care, the outcomes measured must reflect the aspects of health that are meaningful to the patient.5–7
Specific to the athletic patient population, authors of epidemiology studies8–10 reported that lower extremity (LE) musculoskeletal injuries accounted for the majority of injuries sustained by this population. An LE injury affects the hip, groin, thigh, knee, shank, ankle, foot, or toes.10 According to the World Health Organization (WHO), musculoskeletal conditions “encompass a spectrum of conditions, from those of acute onset and short duration to lifelong disorders.”11 Musculoskeletal injury has the potential to affect many facets of life, including physical and emotional wellbeing. The impairments and limitations resulting from musculoskeletal injury vary depending on the specific condition and patient.
Medical attention and treatment for LE injuries are often provided by a team of health care professionals. Optimal management requires the medical team to have a standardized language, enabling communication about patients' health, disability, and functioning across various disciplines.12 Furthermore, health outcomes assessed by the medical team must account for all dimensions of health, including physical, psychological, and social well-being.13 The adoption of the WHO's International Classification of Functioning, Disability and Health (ICF) has facilitated such efforts in health care. The ICF is the official standard defining and quantifying health and disability.12 Endorsed by the Athletic Training Strategic Alliance, the ICF should be used by the athletic training profession for delivery of and communication about patient care.14 The ICF (Figure 1) classifies health, disability, and functioning according to impairments of body functions and structure, activity limitations, participation restrictions, and personal and environmental factors.12
The ICF framework is built on a hierarchical structure for implementation in common practice and consists of 4 components, each represented by an alphabetical coding system: body functions (b), body structures (s), activities and participation (d), and environmental factors (e). Each component is further divided into domains (up to 4 levels), represented by alphanumeric codes.12 One digit denotes a first-level domain (eg, mental functions, b1), 3 digits denote second-level domains (eg, sensation of pain, b280); 4 digits, third-level domains (eg, pain in body part, b2801); and 5 digits, fourth-level domains (eg, pain in lower limb, b28015). Fourth-level domains identify more precise impairments, limitations, or restrictions, whereas first-level domains capture function and disability from a broad perspective. The ICF system is illustrated in Figure 2.
The ICF has been applied to several patient populations, conditions, and health care professions. To date, no researchers have used the ICF as a framework for capturing the athletic patient population's health and disability, which would contribute to understanding the usefulness of the ICF among athletic trainers (ATs). Whether the patient outcomes reported by collegiate athletes who have sustained an LE injury correspond to the ICF model is unknown. Therefore, the purposes of our study were to (1) determine if the patient outcomes reported by collegiate athletes after LE injury corresponded with the ICF system and (2) identify the most relevant ICF categories and domains for collegiate athletes after LE injury.
METHODS
The first phase of our study15 involved conducting semistructured, face-to-face interviews with collegiate athletes to explore their experiences and meaningful outcomes after LE musculoskeletal injury. General inductive analysis allowed us to identify the themes and personal experiences that were meaningful to the patients. In the second phase, reported here, the data, systematically indexed by themes and subthemes, were linked to ICF second-level domains using established linking rules.16
Participants
Purposive sampling17 was used to recruit participants. Participants were National Collegiate Athletic Association Division I athletes who received care from an AT after sustaining at least 1 LE musculoskeletal injury within the past calendar year. Participants were included in the study if (1) the injury resulted in at least 1 lost day (24 hours) of competition, practice, or conditioning from their sport and (2) they were recovered or in the end phase of recovery from the LE injury. Recovery status was based on the individual's current athletic participation status. To meet the inclusion criteria and be classified as recovered or in the end phase of recovery, participants had to be cleared for activity (full or limited) in their sport by a health care professional. More specifically, the person was allowed to participate in some sort of team-related activity that was sport specific but need not have fully returned to participation. This allowed the athletes to be able to discuss how the injury affected them through each phase of recovery. Although participation status may not serve as the most accurate qualifier for identifying recovery status among the general population, it is an identifiable and measurable qualifier for the athletic patient population. Injury severity was determined by self-reported time lost from athletic participation. Any injury that resulted in a loss of greater than 3 weeks of sports participation was categorized as a severe injury.18,19 A moderate injury was defined as any injury that resulted in participation restriction of greater than 1 day and less than 3 weeks.18,19 We interviewed 20 participants (10 men, 10 women; mean age = 20.1 ± 1.83 years; 10 severely injured, 10 moderately injured) before data saturation was achieved. Additional demographic information was presented in Part 1.15
The ICF Linking Process
The meaningful concepts that were derived from the interviews as qualitative data were linked to second-level ICF categories by 2 independent researchers. The linking rules involved 3 steps: (1) develop an understanding of the ICF categories and domains, (2) link each meaningful concept derived from the data to the most similar ICF second-level domain or domains,16 and (3) compare and discuss the researchers' independently linked concepts to ensure agreement.20 A third researcher was available in the case of ambiguity; however, no disagreements occurred. In some instances, the data were linked to more than 1 second-level domain and, therefore, potentially to more than 1 first-level domain and ICF category. For example, the following statement was categorized under the 3 second-level domains attention functions (b140), focusing attention (d160), and maintaining a body position (d415):
It rearranged your focus, like sitting in class for 2 hours and your foot would be throbbing . . . You'd lose track of the topic and start thinking about your foot and try to figure out what's on the board.
It was also linked to the first-level domain mental function (b1) under the category body function (b), as well as the first-level domains learning and applying knowledge (d1) and mobility (d4) under the category activities and participation (d).
RESULTS
The data from the qualitative interviews were successfully linked to 63 ICF second-level domains across all 4 categories (Figure 3). These second-level domains corresponded with 20 first-level domains (Table). The results are presented in the Appendix, including participant quotes and the terms that were linked to the ICF second-level domains. Affiliated with body functions (b), 20 second-level domains were linked to participant interviews. The 20 second-level domains fell under 6 first-level domains (Figure 4). Under the activities and participation (d) classification, 28 second-level domains and 7 corresponding first-level domains were linked to participant responses (Figure 5). We linked 12 second-level domains under environmental factors (e) to the participant interviews. These corresponded to 5 first-level domains (Figure 6). Three second-level domains were linked to participant interviews under body structures (s) that corresponded with 2 first-level domains (Figure 7).
DISCUSSION
This appears to be the first attempt to investigate the health and disability of collegiate athletes with LE injuries in the context of the WHO's ICF model. The ICF has been adopted internationally as a standard language for describing and categorizing health.21 Therefore, using the ICF as a consistent language to communicate health status among the members of the medical team is paramount to ensure standardization across health care disciplines and geographic regions. Participant responses in this study were linked to 63 ICF second-level domains and categorized under 20 of the 30 first-level domains. Important insights from the interviews contribute to and enhance our existing knowledge regarding outcomes assessment.
Most responses were easily linked to the ICF. For example, several participants discussed having difficulties sleeping, which could easily be connected to the ICF second-level domain sleep functions (b134). Conversely, some concepts that emerged from the data were not easily classifiable. For example, respondents discussed their discontent with relying on others and identified gaining independence as an important milestone in recovery and a marker of health. However, gaining independence was more difficult to link to first- or second-level domains because the responses were more specifically aligned to third- or fourth-level domains. Nonetheless, the general meaning of the participants' responses could be captured using the broader second-level domains. Responses in the current study that referred to gaining independence were linked to the second-level domain undertaking a single task (d210) or undertaking multiple tasks (d220), as performing tasks independently is tied to these domains.
The ability to use stairs was another common activity limitation, yet the term stairs is not specifically cited in the ICF. Similarly, many sport-specific movements or tasks are not explicitly acknowledged in the ICF, such as cutting, pivoting, drilling in wrestling, and reaching top end speed. The ICF practical manual stated: “Disability-related information generated independently of the ICF model and classification may or may not be easily linked to individual categories or codes on a one-to-one basis.”21(p44) The manual refers to the Cieza et al16 linking rules for organizing and classifying information. According to Cieza et al,16 “Each meaningful concept is linked to the most precise ICF category.”
Previous researchers have successfully linked the ICF to various conditions, including hip osteoarthritis,22 neck pain,23 plantar fasciitis,24 meniscal and articular cartilage lesions,25 and neurodisability.26 Other investigators have explored broader contexts by identifying functioning and health as they relate the ICF to larger patient populations with unique characteristics, including geriatric patients27 and children and youths.28 Using the ICF to categorize health and functioning allows clinicians to identify evidence-based interventions to address impairments of body functions and structures, activity limitations, and participation restrictions. Also, it enables clinicians to properly assess changes in health status by identifying appropriate outcome measures that encompass all components of functioning and health.
Our results provide the foundation for confirming that the ICF model is suitable for the athletic population. All outcomes identified by the participants fit in the ICF. However, our focus was solely on LE musculoskeletal injury; therefore, it is important to explore the upper extremity, head and neck, and trunk. An outcome instrument that encompasses health outcomes significant to athletic patients should also be identified. Specifically, the 63 second-level domains described by the athletes could represent the first step in creating an outcome instrument based on the ICF model. Identifying meaningful outcomes represents one of the rudimentary yet crucial steps for the genesis and validation of an outcome instrument.
Determining meaningful patient outcomes is a foundational component of providing patient-centered care, so our results have direct clinical and research applications. From a clinical perspective, our findings should prompt ATs to embrace the concepts provided in the ICF. Considering that all of the outcomes described by the athletes fit under the conceptual umbrella of the ICF, this offers a clinical compass for ATs to identify and subsequently document and track their patients' outcomes. Furthermore, even if an outcomes instrument addressing all of these constructs does not exist, ATs can and should ask these questions of their patients in their assessments and daily patient interactions and then document and monitor changes as the patient recovers. From a research perspective, now that we have this clinical compass pointing us toward the concepts of function and disability that are deemed important to our recovering patients, what we should be measuring is clear as we attempt to determine the value of athletic training services. For example, any investigation into athletic training outcomes that considers only physical limitations and ignores the mental, social, and environmental factors associated with patient recovery will be limited in scope and influence. Furthermore, our work provides insight into the constructs of health and function that must be included in any instrument that is to be used in, or developed for, athletic training clientele.
The creation of a new instrument may be justified; however, the possibility that the ICF domains acknowledged in this study are addressed in previously validated instruments should be explored. Investigations should include the ICF-based instruments developed by the WHO, including the ICF Checklist,29 the WHO Disability Assessment Schedule 2.0,30 and the ICF Core Sets.31 Several outcomes identified in this study, such as pain, mobility, self-care, and major life areas, are commonly assessed among the general population using instruments such as the 36-item Short-Form Health Survey.32 These common dimensions of health are just as meaningful to the athletic population and must be measured using an appropriate outcome instrument. Similarly, unique aspects of health, such as the sport-specific skills described by participants in this study, must be taken into account when seeking an adequate outcome instrument.
It is also important to attain a consensus or shared vision among patients and health care professionals regarding the core aspects of health that are of primary concern. Future researchers should determine and attain consensus on what health care professionals regard as meaningful for outcomes assessment.
CONCLUSIONS
The functioning described by athletic training patients recovering from LE injuries matched the standard language of the ICF. The meaningful outcomes they described were successfully linked to 63 ICF second-level domains and 20 corresponding first-level domains that spanned all 4 of the ICF categories. Since the endorsement of the ICF by the Athletic Training Strategic Alliance, this is the first step in understanding and applying the ICF to the athletic training discipline. Our results confirm that the ICF serves as a universal standard to identify and assess impairments, limitations, and restrictions among various patient populations, including athletes after LE injury. Furthermore, ATs now have a clear pathway for identifying and documenting their patients' outcomes. Even if an ideal instrument does not exist, clinicians can still address these constructs in their assessments and daily patient interactions. It is essential for ATs to incorporate these universally accepted health outcomes in order to deliver patient-centered care.
