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Mapping Patient-Specific Functional Scale (PSFS) Items to the International Classification of Functioning, Disability and Health (ICF) Kate Fairbairn, Kate May, Yvonne Yang, Sharan Balasundar, Cheryl Hefford and J. Haxby Abbott PHYS THER. 2012; 92:310-317. Originally published online November 10, 2011 doi: 10.2522/ptj.20090382

The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/92/2/310 Collections

This article, along with others on similar topics, appears in the following collection(s): Disability Models International Classification of Functioning, Disability and Health (ICF) Musculoskeletal System/Orthopedic: Other Outcomes Measurement Tests and Measurements

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Research Report Mapping Patient-Specific Functional Scale (PSFS) Items to the International Classification of Functioning, Disability and Health (ICF) Kate Fairbairn, Kate May, Yvonne Yang, Sharan Balasundar, Cheryl Hefford, J. Haxby Abbott K. Fairbairn, PT, BPhty, Prohealth Physiotherapy Ltd, Invercargill, New Zealand. K. May, PT, BPhty, West Coast District Health Board, Greymouth, New Zealand.

Background. The International Classification of Functioning, Disability and Health (ICF) provides a common framework for clinical outcome measurement. Because the Patient-Specific Functional Scale (PSFS) is widely used for documenting change over time in individual patients receiving musculoskeletal physical therapy, investigation of the extent to which PSFS items reflect the ICF is needed.

Y. Yang, PT, BPhty, Rockhampton Base Hospital, Queensland Health, Australia.

Objective. The study objective was to investigate the extent to which patient-

S. Balasundar, PT, BPhty, Prime Physiotherapy, Sydney, New South Wales, Australia.

Design. This investigation was an observational content validity study.

C. Hefford, PT, MPhty, School of Physiotherapy, University of Otago, Dunedin, New Zealand. J.H. Abbott, MScPT, PhD, FNZCP, Centre for Musculoskeletal Outcomes Research, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand. Address all correspondence to Dr Abbott at: haxby.abbott@ otago.ac.nz. [Fairbairn K, May K, Yang Y, et al. Mapping Patient-Specific Functional Scale (PSFS) items to the International Classification of Functioning, Disability and Health (ICF). Phys Ther. 2012;92:310 –317.] © 2012 American Physical Therapy Association Published Ahead of Print: November 10, 2011 Accepted: September 26, 2011 Submitted: November 16, 2009

generated PSFS items reflect ICF domains.

Methods. A total of 2,911 PSFS items from 1,050 files for patients with musculoskeletal disorders were analyzed. The data were from a random sample of participants in the Otago Outcome Measures Project at 4 clinics of the School of Physiotherapy, University of Otago, situated in 3 New Zealand cities. Patientnominated PSFS items were categorized and mapped with thematic analysis techniques to ICF components, chapters, and categories. Subgroup analyses were conducted for body region of injury and age ranges.

Results. All (100%) of the analyzed items could be mapped to the ICF. Most patient-nominated items mapped to the activity component (80.0%), some items mapped to the participation component (7.7%), other items were related to impairment (7.4%), and the fourth group contained items that overlapped the activity and participation components (4.9%). Similar results were found for each of the 5 body regions and across age ranges in subgroup analyses.

Limitations. These results are limited to individual patients seeking musculoskeletal physical therapy. Patient-generated PSFS items were investigated. Conclusions. The ICF activity component was most commonly represented by patient-nominated PSFS items, the participation component was moderately represented, and impairment was least represented. Hence, the PSFS would complement impairment-based clinical outcome measures.

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Mapping PSFS Items to the ICF

T

he International Classification of Functioning, Disability and Health (ICF) is a multidimensional framework developed by the World Health Organization “to provide a unified and standard language and framework for the description of health and healthrelated components of wellbeing.”1,2(p3) The framework is intended to improve communication among different users, such as health care workers, researchers, policy makers, and the public, including people with disabilities.2 The ICF framework comprises 3 principal components— body functions and structures, activities, and participation (Tab. 1)—within the context of personal and environmental factors (Fig. 1).2 Within each component, chapters define aspects of health and well-being (Tab. 2). Within each chapter, items are further divided into domains and categories.2 At each level, items become more specific and defined. Physical therapists use the ICF framework to support rehabilitation through an individualized but holistic approach when considering intervention for a patient.3,4 In a patient-centered approach, the ICF model is intended to help physical therapists identify relevant limitations of individual patients across the components. Within physical therapy, it is considered best practice to use standardized outcome measures for routine assessments of patients’ conditions.1 Optimally, these measures should reflect the ICF model to ensure that the assessments cover all aspects of well-being. Researchers have noted that therapists have tended to focus on assessing impairment of body functions and structures5–7; however, for optimal health, an individual should be able to actively function and participate in all aspects of daily life, such as family relationships and community activities. The ICF is not, in itself, an outcome measure February 2012

Table 1. Definitions of Aspects of the International Classification of Functioning, Disability and Health (ICF) Modela Component Body functions and structures

Definitions Body functions are physiological functions of body systems (including psychological functions) Body structures are anatomical parts of the body, such as organs, limbs, and their components Impairments are problems in body functions or structures, such as significant deviation or loss

Activities

Activities are tasks or actions executed by an individual Limitations are difficulties that an individual may have in executing activities

Participation

Participation is involvement in life situations Restrictions are problems that an individual may experience with involvement in life situations

a

For further clarification, see Annex 1 of the ICF.2

instrument; it is a taxonomy of aspects of health and health-related domains so exhaustive in scope that a clinician could not hope to consistently apply the breadth and depth of it to each patient.8 The development and validation of new measures to specifically assess each component of the ICF can be timeconsuming and expensive; therefore, it may be preferable to assess

the consistancy of existing measures with the ICF.9 Many existing outcome measures are commonly used within physical therapy. Outcome measures can range from generic to specific for a body region, health condition, or dimension.6 Patient-specific outcome measures are applicable to a wide range of health conditions and provide

Health condition (disorder or disease)

Body functions and structures

Activities

Environmental factors

Participation

Personal factors

Figure 1. Interactions among the components of the International Classification of Functioning, Disability and Health. In later revisions, activities and participation were combined, as were personal and environmental factors. Reprinted with permission from the World Health Organization. International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. Copyright 2001, World Health Organization.

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Mapping PSFS Items to the ICF Table 2. International Classification of Functioning, Disability and Health (ICF) Components, Chapters, and Categories Represented by Patient-Nominated Items of the Patient-Specific Functional Scale (PSFS)

Chapters Represented

ICF Component Body functions and structures

Activities and participation

Categories Represented

Mental functions

Physical Therapy

96

44.4

b134

92

42.6

Attention functions

b140

4

1.8

Sensory functions and pain

b2

2

0.9

Functions of cardiovascular, hematological, immunological, and respiratory systems

b4

5

2.3

Functions of digestive, metabolic, and endocrine systems

b5

1

0.5

Neuromuscular and movementrelated functions

b7

101

46.8

Structure-based impairment

s7

11

5.1

Communication

d3

1

⬍0.1

d4

2,152

79.9

Changing and maintaining body position

d410–d429

635

23.6

Carrying, moving, and handling objects

d430–d449

457

17.0

Walking and moving

d450–d469

941

34.9

Moving around using transportation

d470–d489

119

4.4

Self-care

d5

168

6.2

Domestic life

d6

118

4.4

Acquisition of necessities

d610–d629

6

Household tasks

d630–d649

74

Caring for household objects and assisting others

d650–d669

38

Interpersonal interactions and relationships

d7 d7702

1

⬍0.1

Work and employment

d8 d850

33

1.2

Community and social life

d9 d920

241

8.9

patient-centered, individualized assessments.10 The Patient-Specific Functional Scale (PSFS) was developed by Stratford et al11 in 1995. Their aim was to develop an instrument that would be easy to administer and applicable to a wide range of clinical presentations and that would provide a comparison of each patient’s specified activity level with the patient’s preinjury state.11 Initially, patients are asked to identify 3 to 5 important activities with which f

Proportion of Items Within a Component (%)

Sleep

Mobility

312

ICF Code b1

No. of Times an Item Was Nominated

they are having difficulty as a result of their condition or injury. Next, patients are asked to rate each activity on a scale from 0 to 10, with 0 representing the inability to perform the activity at all and 10 indicating the ability to perform the activity at the same level as before the injury or condition.11 To date, the PSFS has been found to be valid, reliable, and responsive to change in a limited range of patient

populations,12 including those with knee dysfunction,13 lower back pain,11 neck dysfunction,14 and cervical radiculopathy.15 In comparison with 9 other patient-specific musculoskeletal outcome measures, the PSFS showed good content validity, generalizability, and feasibility.10 The extent to which items of the PSFS are thematically consistent or different between individuals because of characteristics such as age or body region affected is not known. Because body

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Mapping PSFS Items to the ICF regions have distinctly different principal functions (eg, the lower limb for locomotion and support; the upper limb for manual interactions with the environment; the neck for moving sensory organs, in particular, the eyes), it is possible that the types of PSFS items generated by people may differ across body regions affected. Similarly, when asked to identify important activities with which they are having difficulty, people in different age ranges may have different priorities or perceptions of what activities they consider to be important or what activities present them with difficulty. Therefore, the types of PSFS items generated by people may differ across the life span. Because the items nominated by patients vary among patients as a result of type of injury, patients’ characteristics, and life situations, it has been recommended that the PSFS be used primarily as a clinical measure of change at the individual level and that it should not be used for describing or comparing grouplevel data.10,14 The research literature on the PSFS is limited with respect to the nature of the items that patients nominate. To our knowledge, no current research has classified the extent to which the PSFS reflects the ICF framework. The aim of this study was to investigate the extent to which PSFS items nominated by patients with a wide range of musculoskeletal disorders reflect the components of the ICF.

Method This investigation was an observational study of the content validity of the PSFS in relation to the ICF. The Otago Outcome Measures Project recruited a prospective cohort of patients presenting at clinics of the School of Physiotherapy, University of Otago, situated in 3 cities in New Zealand. The PSFS is routinely completed during the initial assessment at these clinics. A random sample of February 2012

350 eligible patients’ files was selected from each center (Dunedin, Christchurch, and Wellington, for a total of 1,050 files) for review in this study by use of a computergenerated random-number sequence (Microsoft Excel, Microsoft Corp, Redmond, Washington). We decided that a minimum of 1,000 files would glean about 3,000 items, which would be more than adequate to ensure data saturation and thus generalizable results.16 Study Participants People were either self-referred or referred by a general medical practitioner to the clinics for various musculoskeletal conditions. The clinics in Dunedin and Wellington are situated within university campuses; thus, many of the patients were university students or staff. The clinic in Christchurch is located in an urban community and offers physical therapy services to the general public across all age ranges. Patients’ conditions were assessed and treated by staff physical therapists and student physical therapists at the clinics. Participating Physical Therapists Registered and student physical therapists both undertook assessments of patients’ conditions. The clinics of the School of Physiotherapy, University of Otago, are structured for clinical education, providing student physical therapists with the opportunity to practice under supervision. During the initial assessment, the physical therapist would apply the PSFS with the patient. A standardized phrase was used to instruct patients to identify 3 to 5 activities that they were unable to perform or with which they were having difficulty as a result of their problem. Next, patients were asked to rate their ability to perform each activity on a numeric rating scale from 0 to 10. Item scores were not aggregated.

Data Analysis We used a thematic analysis technique17 to categorize and map the PSFS items nominated by each patient to the predefined components, domains, and categories of the ICF. Rules developed by Cieza et al18 to increase the reliability of linking concepts contained in health-related outcome measures to the ICF were used to guide the mapping of PSFS items to the ICF in a standardized manner. Individual items were coded and aggregated into impairment, activity, or participation in accordance with ICF definitions.2 Within the ICF model, it can be challenging to differentiate between activities and participation.2,19 To overcome this challenge, we adopted the fourth approach in Annex 3 of the ICF,2 as recommended by the Australian Institute of Health and Welfare.20 In this approach, items are classified into activity or participation within the context of how patients described the items and how therapists interpreted and recorded them. In accordance with the findings of Dixon et al,21 items that overlapped the activity and participation components were placed in a fourth group. To increase the validity of the results, the mapping process was completed independently by 2 groups of 2 authors (Y.Y. and S.B.; K.F. and K.M.).22,23 The results then were compared and discussed by the 2 groups. A third party (J.H.A.) was consulted if the groups could not reach agreement. To express the extent to which the PSFS represents the ICF, we calculated the proportions of PSFS items that we were able to map to each of the chapters within the ICF components (body functions and structures, activities, and participation). To investigate whether representation of the ICF differed for body

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Mapping PSFS Items to the ICF Table 3. Proportion of Items of the Patient-Specific Functional Scale Representing Each Component of the International Classification of Functioning, Disability and Health, by Age Age Range of Patients (No. of Items)

% (No.) of Items Representing the Following Component: Body Functions and Structures

Activities

Participation

Activities and Participation

9.3 (59)

4.2 (27)

⬍20 y (636)

6.4 (41)

20–29 y (911)

7.0 (64)

79.3 (722)

7.8 (71)

5.9 (54)

30–39 y (403)

7.7 (31)

81.4 (328)

6.7 (27)

4.2 (17)

40–49 y (384)

9.4 (36)

78.4 (301)

6.3 (24)

6.0 (23)

50–59 y (258)

7.8 (20)

81.4 (210)

7.0 (18)

3.9 (10)

⬎59 y (316)

7.6 (24)

81.3 (257)

7.6 (24)

3.5 (11)

Other (3)

0.0 (0)

100 (3)

0.0 (0)

0.0 (0)

Total (2,911)

7.4 (216)

80.0 (2,330)

7.7 (223)

4.9 (142)

regions or age ranges of patients, we conducted subgroup analyses for body region of injury (back, upper limb, lower limb, neck, and other) and age ranges (⬍20, 20 –29, 30 –39, 40 – 49, 50 –59, and ⬎59). When more than one body region was recorded in the raw data, we used a Read Code24 and items nominated by the patient to decide on the one most representative body area. Role of the Funding Source This study was supported by the New Zealand Lottery Health Grants Board and the New Zealand Society of Physiotherapists Scholarship Trust. The sponsors had no role in any aspect of the study design, conduct, analysis, interpretation, or reporting.

80.0 (509)

Results A total of 2,911 patient-nominated PSFS items from 1,050 patients’ files were included (Tabs. 2, 3, and 4). The mean age of the patients was 34.3 years (range⫽9 –91 years) (Tab. 3). Both sexes were well represented (50.2% female, 49.8% male), and body areas represented included the neck (9.7%), back (23.1%), upper limb (19.9%), lower limb (47.0%), and other (0.3%) (Tab. 4). Most of the physical therapy services could be claimed under the New Zealand Accident Compensation Corporation national no-fault accident and injury insurance (73.7%). Most patient-nominated PSFS items were classified into activity (80.0%),

and some were classified into participation (7.7%) and impairment (7.4%). The fourth group, which contained items that overlapped the activity and participation components, represented the remaining proportion (4.9%) (Fig. 2). Subgroup analysis for age ranges indicated that age did not influence the proportions of the ICF components represented by the patient-nominated PSFS items (Tab. 3). Activity-based items consistently represented the highest proportion of items reported across all body regions; however, neck problems were associated with a higher proportion of impairment-based items (29.3%) than were problems with the back, upper limb, lower limb,

Table 4. Proportion of Items of the Patient-Specific Functional Scale Representing Each Component of the International Classification of Functioning, Disability and Health, by Body Region % (No.) of Items Representing the Following Component: Region (No. of Items)

Activities

Participation

Activities and Participation

Neck (283)

29.3 (83)

57.6 (163)

8.5 (24)

4.6 (13)

Back (671)

8.0 (54)

77.8 (522)

8.0 (54)

6.1 (41)

Upper limb (580)

6.2 (36)

81.2 (471)

6.4 (37)

6.2 (36)

Lower limb (1,369)

3.0 (41)

85.4 (1,169)

7.8 (107)

3.8 (52)

Other (8) Total (2,911)

314

Body Functions and Structures

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25.0 (2) 7.4 (216)

62.5 (5) 80.0 (2,330)

12.5 (1) 7.7 (223)

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0.0 (0) 4.9 (142)

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Mapping PSFS Items to the ICF and other areas (Tab. 4). This difference comprised almost entirely the body function item “turning the head” (ICF code b710: mobility of joint functions). The “other” group consisted of rib and thorax injuries.

Discussion Our findings indicated that items selected by patients completing the PSFS predominantly represented the activity and participation components of the ICF, with low representation of impairment of body functions and structures. Our findings showed that the highest proportion of PSFS items nominated by patients represented the activity component (80%); the participation component was moderately represented when considered alone or in combination with the activity component (12.6%). Impairment of body functions and structures was represented by 7.4% of the PSFS items nominated by patients with musculoskeletal disorders. The lower proportion of impairment-based items indicated that the breadth and depth of the ICF and its components were not fully represented by the PSFS alone. The high representation of activitybased items could have been a consequence of the standardized phrasing used in the administration of the PSFS. Patients were asked to describe 3 to 5 activities; this phrasing might have caused bias away from impairment- or participationbased items. Jolles et al10 also raised this point when investigating the content validity of the PSFS, concluding that the PSFS only partially met their content validity standards. The creators of the PSFS did not identify why the word “activity” was used,11 and it is possible that an instrument with different terminology would encourage patients to think beyond activities to include participation or impairment. However, conversely, different terminology might result in weakened representation of activityFebruary 2012

Figure 2. Proportion of items representing each component of the International Classification of Functioning, Disability and Health. Impairment⫽impairment of body functions and structures.

based items, and further research would be needed to ascertain whether the change in wording affected the properties of the PSFS. In addition, different terminology might present difficulties in conveying the differences in the components to patients, considering the difficulties encountered in differentiating between participation and activities within the ICF model.2,19 Although the PSFS strongly represented the activity component of the ICF and partially represented the participation component of the ICF, impairment of body functions and structures was not strongly represented (except in the neck). This finding indicated that the PSFS should be supplemented by complementary outcome measures addressing impairments. Other researchers have noted that physical therapists

are more inclined to use outcome measures of impairments, such as pain and range of movement6,25; the addition of the PSFS would complement these measures by representing the activity and participation components. Brockow et al6 reported that the dominance of impairment-based outcome measures also appeared in clinical research. They found that in 836 outcome measures reported in clinical trials for lower back pain, chronic widespread pain, osteoarthritis, osteoporosis, and rheumatoid arthritis, impairment of body structures and functions was most commonly represented.6 For lower back pain, chronic widespread pain, and osteoarthritis, the categories most commonly used were sensation and pain; the categories most commonly used for osteoporosis and rheumatoid arthritis were structures related to the trunk and other musculoskeletal

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Mapping PSFS Items to the ICF structures related to movement, respectively.6 By using the PSFS in conjunction with commonly used impairment-based outcome measures for individual patients, physical therapists would capture a wider range of the ICF components. The dominance of activity- and participation-based items in the PSFS might improve coverage of the breadth of the ICF. We investigated the consistency of representation of ICF components across body region subgroups. The findings from this analysis revealed that patients with injuries in the neck selected a somewhat lower proportion of activity-based items and a higher proportion of impairmentbased items than patients with injuries in the other body regions. Most of the impairment-based items were associated with the body function item “turning the head” (ICF code b710: mobility of joint functions). Overall, the neck was shown to have the broadest representation of ICF components because it was associated with the most impairmentbased items and 1 of the highest proportions of participation-based items. Differences between body regions were not marked, indicating that the PSFS ably represented all body regions affected by musculoskeletal complaints seen in outpatient physical therapy practice. We saw no notable differences between age ranges with regard to the proportions of items representing each ICF component. This research has highlighted the difficulties encountered in differentiating between activities and participation within the ICF model. Earlier drafts of the ICF model described activities and participation as 2 separate components (Fig. 1); however, in the 2001 version of the ICF, activities and participation were grouped together.2,19 Annex 3 of the ICF2 suggested 4 ways of classifying items as either activities or participation 316

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but did not provide rules for doing so. Dixon and colleagues21,26 and Perenboom and Chorus27 also found that it was difficult to differentiate between activities and participation when they mapped some frequently used outcome measures into the 3 components of the ICF. A fourth group was created in those studies to capture items that overlapped activities and participation. Other investigators have explored possible ways of separating activities from participation.28,29 Badley28 classified items into the categories of acts, tasks, and societal involvement but failed to classify tasks as either activities or participation. Jette et al29 differentiated the items in the Late-Life Function and Disability Instrument as distinct activities or participation. However, the nature of the items in that particular outcome measure was such that the researchers could clearly classify items into the ICF components; this method may not produce the same results when applied to other outcome measures. Other researchers attempting to separate activities and participation used quantitative methods to calculate rates of agreement in differentiating between the components.21,26,30,31 However, because of the lack of clear differentiation between these 2 components, we chose to take a qualitative approach in the present study; this approach involved discussions by researchers to decide into which components items could be classified. We differentiated activities and participation within the context of how they were described.32 A limitation of this method is that items were categorized depending on how patients described the items and how therapists interpreted and recorded them. Collapsing activities and participation under a single taxonomy, as is the case for the ICF model from 2001 to the pres-

ent,2,19 avoids these classification difficulties. The PSFS is intended to serve as an efficient, widely applicable, and responsive measure of change over time at the individual level.11,14 Patient-specific indexes, by definition, focus on issues most relevant to a patient, explicitly from the patient’s perspective. In the present study, we attempted to classify patient-nominated PSFS items into the chapters and categories of the 3 main ICF components— body functions and structures, activities, and participation; however, not all aspects of the ICF were represented in our data. The ICF is intended to contain categories for all aspects of human health and well-being; some of these categories were not relevant to the group of patients whose data we studied (patients receiving musculoskeletal physical therapy). The PSFS is not intended to comprehensively represent the breadth and depth of the ICF or even the much more concise Core Sets because it is limited to only 3 to 5 items (median and mode of 3 in our data). Another point to consider is that the main ICF components— body functions and structures, activities, and participation—should be considered within the context of personal and environmental factors (Fig. 1). Personal and environmental factors may influence which items patients nominate; however, with its focus on activities, the PSFS does not take this possible influence into account, generally failing to represent personal and environmental factors. Silva Drummond et al33 reached a similar conclusion in linking the Disabilities of Arm, Shoulder, and Hand instrument to the ICF, stating that a limitation of the content validity of the Disabilities of Arm, Shoulder, and Hand instrument was its failure to consider environmental factors.

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Conclusion The results of the present study established that patient-nominated PSFS items predominantly represented the activity component of the ICF, with moderate representation of the participation component and low representation of impairment of body functions and structures. Our results were generally consistent across body regions, except that the representation of impairment of body functions was higher in patients with problems in the neck, relating to the ability to turn the head. Our results were consistent across age ranges. The results of the present study support the content validity of the PSFS, which was designed to be a patientspecific measure of activities. On the basis of these findings, we recommend that the PSFS be used as an outcome measure for assessing activities in individual patients. All authors provided concept/idea/research design, data collection, and project management. Ms Fairbairn, Ms May, Ms Yang, Mr Balasundar, and Dr Abbott provided writing and data analysis. Dr Abbott provided fund procurement. Ms Hefford and Dr Abbott provided participants, facilities/equipment, and consultation (including review of manuscript before submission). Approval for this study was attained from the New Zealand Multiregion Ethics Committee (MEC/07/27/EXP). This study was supported by the New Zealand Lottery Health Grants Board and the New Zealand Society of Physiotherapists Scholarship Trust. DOI: 10.2522/ptj.20090382

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Mapping Patient-Specific Functional Scale (PSFS) Items to the International Classification of Functioning, Disability and Health (ICF) Kate Fairbairn, Kate May, Yvonne Yang, Sharan Balasundar, Cheryl Hefford and J. Haxby Abbott PHYS THER. 2012; 92:310-317. Originally published online November 10, 2011 doi: 10.2522/ptj.20090382

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