Spinal cord injury (SCI) results in the impairment of several body functions and therefore, numerous changes occur in the daily lives of SCI patients. When acute SCI occurs, the patient is transported to the emergency room and undergoes operation, if necessary. After the vital sign and the patient status are stabilized, the rehabilitation process begins. In traumatic SCI, adequate timing of medical treatment and rehabilitation is essential for the recovery of functioning. It is known that functioning prognosis is better if the time lapse from the injury to the rehabilitation department admission is shorter.1 The concept of "post-acute rehabilitation" can be understood as the rehabilitation process being initiated as soon as possible after acute medical management.2 In the rehabilitation of SCI patients, specific therapies, such as physical therapy, occupational therapy, and respiratory rehabilitation therapies should be carried out simultaneously, and medical treatments for symptoms including orthostatic hypotension, pain, and spasticity, are also required. Considerations on socioeconomic aspects, such as occupation, are also important because the age group of SCI patients are younger compared to the other disease categories, such as stroke. As described above, rehabilitation of SCI patients requires focusing on various aspects. Therefore, a comprehensive evaluation on the patient's medical, functional, and social status is necessary before planning the rehabilitation therapy and goals.3 In the comprehensive evaluation of SCI, the problem list oriented approach is known to be more useful than the individual approach by each rehabilitation team member.4

In 2010, Kirchberger and colleagues2,5 suggested the International Classification of Functioning, Disability and Health (ICF) core sets for acute and chronic spinal cord injury. ICF core set is a list of important items regarding the evaluation of functioning and disability in a specific disease entity, by gathering opinions and consensus from experts of that specific disease. Specifically, it is a collection of relevant factors involved in common functional impairments and environmental factors that must be taken into consideration. The ICF core set is established for many disease categories because the whole ICF classification system is very extensive.6-8

Rauch et al.9 suggested that the ICF core set can be used to describe the patient's functioning status comprehensively and a more efficient approach can be made for rehabilitation by application of the ICF core set. They also conducted and analyzed the comprehensive evaluation of one spinal cord injury person and suggested a conceptual framework of the comprehensive evaluation.10 But to our knowledge, the practical proposal on the usage of ICF in the clinical rehabilitation field has not been reported so far. In our hospital, we have been conducting a comprehensive evaluation for SCI patients for 3 years from 2008 by the problem list oriented method based on the ICF 1st level classification. In this study, we analyzed the comprehensive evaluation records and coded the contents according to the ICF 2nd level classification. We aimed to investigate the utility of the ICF in the problem list oriented comprehensive evaluation of post-acute SCI patients and suggest a specific practical method of evaluation.

In our hospital, when a patient is admitted to the rehabilitation unit, comprehensive evaluation is carried out within 1-2 weeks. The patient is evaluated in various aspects, and then, the short-term and long-term rehabilitation goals are set. Every rehabilitation team member involved with the patient in any way participates in the comprehensive evaluation meeting. The rehabilitation team consists of physiatrists, physical therapists, occupational therapists, nurses, nutritionists, medical socialworkers, etc. Prior to the year 2008, the comprehensive evaluation was conducted from the viewpoint of each rehabilitation team member. However, from 2008 and on, the evaluation was accomplished within a framework of the ICF 1st level classification (Fig. 1). The evaluation form was created according to the problem list oriented method based on the ICF 1st level classification. Each rehabilitation team member filled out the blanks for each category with the contents they have assessed and evaluated. Then, all of the members joined the meeting and participated in active discussions about the evaluation contents.

ICF is an international classification system to describe the health and health related status developed by the World Health Organization (WHO) in the year 2001 in order to enable a comprehensive and multidisciplinary approach to health and disability. ICF divides factors of health status as "functioning and disability" and "contextual factors." Functioning and disability is divided into the body functions and structures domain and the activities and participation domain. The contextual factors are divided into the environmental factors and personal factors. The ICF code is classified into 4 domains. First level classification consists of 30 items, second level has 362 items, and third to fourth level consists of 1,424 items.11

A brief ICF core set and comprehensive ICF core set has been published for post-acute SCI.2 The comprehensive ICF core set consists of 63 body function items, 14 body structure items, 53 activities and participation items, and 32 environmental factor items, with a total of 162 categories. Of these items, 8 body function items, 3 body structure items, 9 activities and participation items, and 5 environmental factors construct the brief ICF core set, with a total of 25 categories.

In this study, we hypothesized that a more systematic approach for acute SCI patients would be possible if the ICF classification is used in the initial comprehensive evaluation for rehabilitation. The aim of this study was to analyze the contents of the comprehensive evaluation records and compare it with the brief ICF core set, and to suggest a guideline for an initial approach for rehabilitation. There were many researches on the necessity of the ICF in a comprehensive evaluation; yet, to our knowledge, there were few researches on the practical usage of the ICF based on the analysis of clinical cases.

In our hospital, comprehensive evaluation is an important process that takes place within 1-2 weeks after patient admission to the rehabilitation unit. All rehabilitation team members that are involved in the rehabilitation process of the patient, such as physiatrists, physical therapists, occupational therapists, speech therapists, nurses, nutritionists, and medical social-workers, gather in one place to discuss the patient's status and establish short-term and long-term rehabilitation goals, and also make treatment plans. Prior to the year 2008, there were no specific forms for evaluation, and thus, each rehabilitation team member presented the patient's status in the view of their professionals, intuitively. For example, physiatrists mentioned medical problems primarily, physical therapists assessed on gait, muscle power, and joint problems, whereas medical social-workers focused on the socioeconomic aspects. From 2008, the evaluation form was established based on the ICF 1st level classification. With this form, every team members wrote their evaluation in each space according to the corresponding problem list and classification. More than one member could comment on the same problem list according to each member's point of view.

In the body function domain, muscle power functions, urination functions, defecation functions, and sensation of pain were frequently mentioned. These items involve problems that most of the SCI patients suffer, which is directly influenced by the spinal cord injury itself.17 Emotional functions, protective functions of the skin, weight maintenance functions, and energy and drive functions were categories that were mentioned in 40-50% of the subjects, which are secondary problems that occur because of impaired transfer and gait. Categories related to the primary effects mentioned above and the secondary effects, such as emotional functions and protective functions of the skin, are also included in the brief ICF core set, suggesting that these factors should always be evaluated.2 In contrast, weight maintenance functions and ingestion functions were not included in the brief ICF core set although many SCI patients complain of weight loss, dysphagia, and anorexia.18 Blood pressure functions were linked in 14.5% of the subjects, which is consistent with the fact that many SCI patients experience orthostatic hypotension during the attempt to stand after several days of bed rest. Orthostatic hypotension is a common symptom in post-acute SCI patients; hence, blood pressure should be considered in the process of rehabilitation and evaluation.19 Sleep function is also another important factor in the clinical environment, often presented as insomnia.18

In the body structure domain, spinal cord and related structures were linked in 100% of the subjects because all of the subjects included in this study were SCI patients. This suggests that the extent and location of the injury should be evaluated exactly by physical examination and by additional lab studies, such as MRI. The structure of the respiratory system and the structure of the urinary system had linking frequencies of 9.7% and 4.8%, respectively, mentioned in less than 10% of the subjects. In these cases, many subjects had impairment of related functions; however, these items were not linked if they did not go through tracheostomy or cystostomy. In Korea, patients or families tend to reject suggestions for tracheostomy and cystostomy, particularly within 90 days after injury onset. Respiratory and urinary structures are important, but personal and environmental factors seemed to make linking frequencies of these categories low.

In the activities and participation domain, items related with activities of daily lives were frequently mentioned. Transferring oneself, walking, toileting, washing oneself, and dressing had a high linking frequency of more than 85%, which are common problems in both tetraplegia and paraplegia. Categories related with mainly the upper extremity usage, such as hand and arm use, drinking, and eating, were linked in 50-60% of the subjects. Patterns of functioning and disability differ according to the level of injury, therefore, this must be considered in the evaluation.20 Most of the items in this domain were also included in the brief ICF core set except for basic interpersonal interactions and remunerative employment. This implies that most of the SCI patients suffer similar problems in the aspect of activities and participation.

In the environmental factor domain, "immediate family" who are primary caregivers, "health professionals" who are responsible for medical care, and "products and technology for personal indoor and outdoor mobility and transportation" which are important in overcoming the impaired transfer function, were very frequently linked, in over 95% of the subjects. In particular, the importance of family support and the social environmental factors were emphasized in many researches recently.21,22 These factors are also the important basis of the rehabilitation goal setting in our clinic.18

With regards to the personal factors, insight on prognosis was considered in 29.0% of the subjects, which was also an important factor in setting the rehabilitation goals. It would be ideal for the patient to know the current disease state and set realizable rehabilitation goals. However, in some cases, it was helpful for early rehabilitation by allowing the patient to realize the exact prognosis after some time has passed, considering the mental factors, age, occupation, and other environmental factors. Thus, in the comprehensive evaluation, all considerations should be taken into account in order to decide when to deliver the bad news to the patient. Kim and Shin23 reported that according to a survey based study, 44.1% of people answered that exact prognosis should be told to the patient within 1 months after injury, and 29.3% answered between 1 to 3 months.

For the personal factors in SCI, the individual's social status, personal history, emotion, thinking, belief, motivation, and behavioral patterns are the main factors that have to be considered.24 In this study, body function factors related with behavior, emotion, and mental status seemed to be overlapping with personal factors, making the linking process complicated. In this case, we linked those contents to the corresponding body function categories if proper category exists, and linked them to personal factors if not.

Overall, 82.4% of the evaluation contents were covered by the brief ICF core set. In other words, 17.6% of the evaluation could have been omitted if the evaluation was only performed by the brief core set. Particularly in the activities and participation domain, the coverage rate of the brief ICF core set was high as 96%, which seemed to be due to the fact that most of the SCI patients suffer similar situations regarding activities of daily lives, and these items became the main focus in the comprehensive evaluation. The coverage rates of the brief ICF core set in the body function domain (73.0%) and environmental factor domain (77.0%) are lower than the average. Different underlying diseases or medical conditions as well as various economic and social backgrounds of each patient could be a good explanation for this disparity. Many contents, other than the brief ICF core set items, have been mentioned during the comprehensive evaluation process in the body function and environmental factor domains.25 The linking frequency of the brief ICF core set categories are listed in Table 3. The additional factors that were discussed in the comprehensive evaluation, but not included in the brief ICF core set, are listed in Table 2, in the order of linking frequency.

The time standard for the period of acute spinal cord injury is not exactly defined. However, Sumida et al.26 suggested that the neurologically acute stage is until 1 week after the onset of injury, subacute stage is from 2 weeks to 4 weeks after injury, and that 3-6 months after injury is the chronic stage when the neurological recovery rate is slowed down. Wuermser et al.17 stated that most of the neurological recovery process takes place within 3 months after injury. Integrating the above opinions, we can consider that initiating rehabilitation at least within 3 months after the injury onset is appropriate in order to designate the rehabilitation as "post-acute rehabilitation." In this study, the average post-onset duration for the initial comprehensive evaluation was 33.4±18.2 days for traumatic SCI patients and 41.3±20.6 days for non-traumatic patients, which was suitable for regarding the rehabilitation of the patients as "post-acute rehabilitation."

There were several advantages in using the problem list oriented comprehensive evaluation based on the ICF 1st level classification from year 2008, compared to the evaluation based on the point of view of each rehabilitation team members. First, sharing detailed information for each problem was possible. For example, for the "transfer" function, the physical therapist described the mat activity pattern, the nurse described the situation of bed to wheelchair transfer, while the doctor gave information on muscle power and spasticity, making it possible for all members to have a three-dimensional concept on the transfer function. Second, more definite and realistic rehabilitation goal could be set according to the problem list. For instance, in the voiding function, it could be difficult to decide whether clear intermittent catheterization or indwelling foley catheter is more appropriate. In these cases, not only the patients themselves, but doctors, medical social-workers, nurses, and occupational therapists shared their opinions based on their point of view, and made the most appropriate decision for the current situation.27

There were also some limitations to this study. The linking process was done only according to whether the contents corresponding to the 2nd level ICF category were mentioned or not, and the ICF qualifiers were not used for the analysis. Thus, the degree of significance for the linked ICF categories in individual patients was not reflected in the analysis. Unfortunately, we could not make task assignments for rehabilitation team members using the ICF based on our results, or make outcome measurements after the rehabilitation treatment. These topics should be considered in future studies.

In this study, we aimed to investigate the utility of the ICF classification and the ICF core set for problem list oriented comprehensive evaluation. But according to the analysis, 17.6% of the comprehensive evaluation contents were not covered by the brief ICF core set. Hence, we need to make an evaluation system as not to omit the additional contents because the brief ICF core set cannot fully substitute the comprehensive evaluation alone. Therefore, for the initial comprehensive evaluation for rehabilitation of SCI patients, we should maintain the problem list oriented framework based on the ICF 1st level classification, and provide the factors of the ICF 2nd level categories that were linked with the high frequency in the evaluation as a checklist. There were several contents that were essential for patient evaluation but not included in the brief ICF core set. Moreover, 44% of the additional factors were not even included in the comprehensive ICF core set; therefore, an evaluation framework with an open question form based on the ICF 1st level classification is necessary.

There have been researches for the utility of ICF in other disease categories. For head and neck cancer, Tschiesner et al.28 stated that an evaluation tool covering all the situations and symptoms could not exist, yet, the ICF could be a definite tool to help standardize and structurize the evaluation of functioning. In a prospective cohort study for post-acute rehabilitation of 116 musculoskeletal, neurological, and cardio-respiratory patients, Lohmann et al.27 insisted that 426 items (78%) out of 546 linked items in the comprehensive evaluation corresponded to the ICF core set; hence, ICF could be helpful for setting rehabilitation goals, yet, the patient's perspective should be considered additionally.

ICF can provide a structural framework for the problem list oriented comprehensive evaluation in rehabilitation. Categories of the brief ICF core set, additional factors mentioned in this study, as well as the personal factors should be considered for the evaluation. Therefore, we should maintain the current framework based on the ICF 1st level categories so that omission of essential contents could be prevented. Additionally, items of the brief ICF core set, additional factors that were frequently mentioned in this study, and personal factors should be provided as a checklist. This would be helpful for the systematic and comprehensive evaluation and serve as a basis for adequate and realistic rehabilitation goal setting.