Journal of Vestibular Research 22 (2012) 261–271 261

DOI 10.3233/VES-120459
IOS Press

International Classification of Functioning,

Disability and Health (ICF) Core Set for
patients with vertigo, dizziness and balance
disorders 1

Eva Grilla,b,c,∗ , Adolfo Bronsteind , Joseph Furmane, David S. Zeef and Martin Müllera,b,c
a
Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität
München, Munich, Germany
b
German Dizziness Center, Ludwig-Maximilians-Universität München, Munich, Germany
c
ICF Research Branch in Cooperation with the WHO Collaborating Centre for the Family of International
Classifications in Germany (at DIMDI), Nottwil, Switzerland
d
Neuro-otology Unit, Division of Brain Sciences, Imperial College London, London, United Kingdom
e
Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA, USA
f
Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA

Received 11 June 2012

Accepted 12 September 2012

Abstract. Vertigo, dizziness and balance disorders have major impact on independence, employability, activities and participation.
There are many measures for the assessment of the impact of vertigo, but no consensus exists on which aspects should be
measured. The objective of this study was to develop international standards (ICF Core Sets) for patients with vertigo and
dizziness to describe functioning.
The development of the ICF Core Sets involved a formal decision-making and consensus process, integrating evidence from
preparatory studies including qualitative interviews with patients, a systematic review of the literature, a survey with health
professionals, and empirical data collection from patients.
Twenty-seven experts selected 100 second level categories for the comprehensive Core Set and 29 second level categories for
the Brief Core Set. The largest number of categories was selected from the ICF component Activities and Participation (40).
Twenty-five categories were selected from the component Body Functions, six from Body Structures, and 29 from Environmental
Factors.
The ICF Core Set for vertigo is designed for physicians, nurses, therapists and other health professionals working in inpatient or
ambulatory settings. ICF Core Sets create patient-relevant outcomes that can be used as evidence for the success of treatments.

Keywords: Vertigo, dizziness, quality of life, activities of daily living, social participation

1. Introduction
1 The responsibility for the content of this publication lies with the

ICF Research Branch. Vertigo, dizziness and balance disorders are major
∗ Corresponding author: Prof. Eva Grill, Institute for Medical
symptoms of health conditions affecting the vestibular
Information Processing, Biometrics and Epidemiology, Ludwig- and central nervous system. They can have a major im-
Maximilians-Universität München, Marchioninistr. 17, D-81377
München, Germany. Tel.: +49 89 2180 78223; Fax: +49 89 2180 pact on independence, employability, activities of daily
78230; E-mail: [email protected]. living and overall quality of life. Lifetime prevalence

ISSN 0957-4271/12/$27.50  2012 – IOS Press and the authors. All rights reserved
262 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders

of moderate to severe vertigo symptoms in the gener- neurological disease [11,12]. Since functioning is an
al population is 20 to 40% [19]; many report associ- important outcome in vertigo and dizziness, it would be
ated disability, psychological problems, or avoidance most helpful to map this group of health conditions to
behaviour [26]. Even without acute symptoms patients salient ICF categories of functioning. Such generally
are disabled because of the worry associated with an- agreed-on lists of ICF categories can be brief to serve
ticipating the next episode. Taking into account all rel- as a description of the functioning of a patient in brief
evant aspects of functioning from the patients’ perspec- clinical encounters or in research, or they can be com-
tive is therefore essential to evaluate new treatments prehensive to guide multidisciplinary assessment and
and to convey the prognosis of the disease. treatment.
There are many measures for the clinical assessment The objective of this study was to develop interna-
of the impact of vertigo and dizziness, but no clear con- tional standards (ICF Core Sets) for patients with verti-
sensus on which measures are the most appropriate or go and dizziness to describe functioning in research and
which aspects should be measured regularly. Existing clinical practice, integrating evidence from preparato-
scales have a limited spectrum, unresolved psychomet- ry studies and input from experts. The ICF Core Set
ric problems [15] or do not take into account all poten- for patients with vertigo and dizziness is designed for
tial aspects of disability encountered with vertigo [1, physicians, nurses, therapists and other health profes-
9]. sionals working in inpatient or ambulatory settings.
Important for the optimal management of vertigo is
an in-depth understanding and reliable measurement of
its consequences. To meet this requirement, a compre- 2. Methods
hensive framework and classification is needed which
can serve as a universal language understood by clini- The development of the ICF Core Sets for vertigo and
cians, researchers and patients alike. With the approval dizziness involved a decision-making and consensus
of the International Classification of Functioning, Dis- process integrating evidence collected from preparato-
ability and Health or ICF by the 54th World Health ry studies. The detailed methods and their rationale
Assembly in May 2001, we have the ICF model that is have been reported elsewhere [10]. In this study, a
accepted worldwide and describes and classifies func- Comprehensive ICF Core Set and a Brief ICF Core Set
tioning, health and disability [23]. Since the ICF is were established. The Brief ICF Core Set is intended
designed to record and organize a wide range of infor- to be a short list of categories and serves as the minimal
mation about health and health-related states both for standard for assessment and description of functioning
individuals and populations, it is applicable both for and disability in clinical studies or in clinical practice,
clinical practice and research. It is likely that the ICF, e.g., for communication across the continuum of care
with its components Body Functions and Structures, or for clinical documentation. The Comprehensive ICF
Activities and Participation, and Environmental Fac- Core Set is designed to serve as a basis for full as-
tors, will become the universal framework in medicine. sessment and documentation, mainly in the context of
The classification, with more than 1400 categories to multidisciplinary care or advanced care planning.
describe and classify functioning, has to be tailored to The ICF classification is hierarchically organized
the needs of the prospective user, without forgoing the with increasing levels indicating increasing degree of
information needed for health statistics and health re- detail. Categories are denoted by an alphanumerical
porting. To address issues of feasibility regarding the code starting with a lower case letter indicating the
number of categories to be assessed and the user per- component, i.e., b for Body Functions, s for Body
spective, which typically consists of a health condition Structures, d for Activities and Participation and e for
and/or situation perspective, the ICF Core Set project Environmental Factors. The letters are followed by a
was initiated in 2001. ICF Core Sets are selections numeric code for the chapter number (one digit, first
of categories from WHO’s International Classification level), followed by the second level (two digits), and
of Functioning, Disability and Health (ICF) that de- the third and forth level (one digit each).
scribe the most relevant and the most common aspects The process of developing ICF Core Sets for verti-
of functioning as well as the most relevant environmen- go and dizziness included four preparatory studies and
tal factors for persons with specific health conditions a consensus conference. The four preparatory stud-
or in specific settings [10]. To date, there are more ies collected data on functioning and disability using
than 30 ICF Core Sets, and some of them focus on different perspectives:
 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders 263

(1) Cross-sectional study: A quantitative study in- Methods and results of the preparatory study were also
cluded 200 patients and represented the clinical presented orally and on posters. Items from the chapter
(epidemiological) perspective. The study yield- Work and Environment were presented to the partici-
ed the prevalence of impairments, limitations, pants both as individual items and as a group of items.
and restriction of various aspects of functioning The decision to present these items in this manner was
as proposed by the ICF. engendered by the preparatory expert survey and by
(2) Qualitative interviews: Patients were asked to the patient interviews wherein it was common that the
talk about how their health condition affected items in the Work and Environment chapter were iden-
their lives. Meaningful concepts were extract- tified as a group rather than only as individual items.
ed from the interviews and linked to ICF cate- The decision-making process consisted of two parts.
gories. This study represented the perspective In the first part, the participants decided which cat-
of the patient. egories should be included in a Comprehensive ICF
(3) Systematic literature review: Outcome measures Core Set. In the second part, the participants ranked the
were retrieved from studies focusing on vertigo chosen categories included in the Comprehensive ICF
and dizziness; these outcome concepts were an- Core Set according to relevance to persons with vertigo,
alyzed and then linked to the ICF. This repre- resulting in the Brief ICF Core Set. In the first step of
sented the perspective of the researcher. the consensus process, each participant was assigned to
(4) International expert survey: This study repre- a working group (WG). There were three WGs. Each
sented the health professionals’ perspective. 188 WG was guided by a WG coordinator (AB, JF and DZ).
international experts identified by authorship, Votes, as well as the key arguments, were recorded on-
recommendation and membership with an aver- line by a group assistant using a database. Group assis-
age experience of 12 years in the area of vertigo tants were not allowed to vote. WG coordinators were
were asked to fill out an online survey regarding asked to cast their vote after the group in order to avoid
the most relevant aspects of functioning in ver- any influential voting. The experts discussed and voted
tigo. These aspects were extracted and linked to for or against inclusion of the ICF categories (Vote A).
the ICF. Experts were selected to represent the The results of all three WGs were then combined and
WHO world regions. presented in a plenary session. Categories that received
The results of all studies led to a pool of 134 second less than 40% of all votes were eliminated at this stage.
level categories (i.e., codes with the component letter Categories that received more than 75% of all votes
followed by three digits) that were potentially relevant were included in the ICF Core Set. After discussions in
to the affected patients. Consensus about which cat- the plenary session, the participants rejoined the WGs
egories to be included in the ICF Core Sets was then for further discussions and a second decision (Vote B)
reached by a structured process of group and plenary on the ambiguous categories. The results of Vote B
sessions. were again presented and discussed in a second ple-
Participants for the consensus conference were cho- nary session. The final decision (Vote C) on the as yet
sen based on their expertise in the management of ver- still undecided ICF categories (40–75% in vote A and
tigo and dizziness, representing four WHO world re- B) was then made in this plenary session. A category
gions. In line with the literature on consensus building was included in the ICF Core Set during Vote C if it
and team work, the ICF Core Set consensus conference received at least 50% yes votes. Also, ICF categories
was organized at a quiet monastery, distant from cities not included in the initially proposed categories could
and distractions. After introduction and training in the be introduced, discussed and voted on at this stage.
concepts of the ICF, the participants identified those In the second part of the decision-making process,
ICF categories considered to be relevant to patients with the experts were asked to assign ranks from 10 to 0
vertigo and dizziness. (10 = most relevant category, 0 = least relevant cate-
Participants were provided with the evidence from gories) to all categories of the comprehensive ICF Core
the preparatory studies. Throughout the conference Set, separately for each component. Ranks were then
participants were advised that their decisions should be summed and ordered according to rank sum. A cut-off
based on this evidence in combination with their per- for the Brief ICF Core Set was determined based on
sonal clinical experience and expertise. The informa- this ranking and on the decisions of the expert partic-
tion included summary sheets of the individual studies ipants about the number of categories to include for
and a list of the ICF categories identified by any study. each component.
264 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders

Table 1
International Classification of Functioning, Disability and Health (ICF) – Categories of the component Body Functions included in the Vertigo
Comprehensive Core Set. Vote A, B, C indicate the stage of the process at which a category was selected (votes A and B were made in the
working groups, vote C was made in the final plenary session). The categories marked with X were included in the Brief Core Set
ICF Category description Vote Brief Core Set
Chapter: Mental functions
b126 Temperament and personality functions A
b130 Energy and drive functions A
b134 Sleep functions B
b140 Attention functions A
b144 Memory functions C
b152 Emotional functions A X
b156 Perceptual functions A X
b180 Experience of self and time functions C
Chapter: Sensory functions and pain
b210 Seeing functions A X
b215 Functions of structures adjoining the eye A X
b230 Hearing functions B X
b235 Vestibular functions A X
b240 Sensations associated with hearing and vestibular function A X
b260 Proprioceptive function A X
b265 Touch function C
b280 Sensation of pain A
Chapter: Functions of the cardiovascular, haematological, immunological and respiratory systems
b410 Heart functions C
b420 Blood pressure functions A
b455 Exercise tolerance functions A
b460 Sensations associated with cardiovascular and respiratory functions A
Chapter: Neuromusculoskeletal and movement-related functions
b710 Mobility of joint functions B
b730 Muscle power functions B
b735 Muscle tone functions C
b760 Control of voluntary movement functions B
b770 Gait pattern functions A X

Table 2
International Classification of Functioning, Disability and Health (ICF) – Categories of the component Body Structures included in the Vertigo
Comprehensive Core Set. Vote A, B, C indicate the stage of the process at which a category was selected (votes A and B were made in the
working groups, vote C was made in the final plenary session). The categories marked with X were included in the Brief Core Set
ICF Category description Vote Brief Core Set
Chapter: Structures of the nervous system
s110 Structure of brain A X
s120 Spinal cord and related structures A X
Chapter: The eye, ear and related structures
s260 Structure of inner ear A X
Chapter: Structures of the cardiovascular, immunological and respiratory systems
s410 Structure of cardiovascular system A X
Chapter: Structures related to movement
s710 Structure of head and neck region A
s750 Structure of lower extremity B

3. Results Preparatory studies identified 134 second level cate-

gories. The resulting Comprehensive ICF Core Set in-
Twenty-seven experts participated in the consensus cluded 100 second level categories. Tables 1 to 4 show
conference, including 19 physicians, four physical ther- the selected categories, the chapter of the ICF to which
apists, one occupational therapist, one sports scientist, each category belongs, and the stages of the process at
one psychologist, one expert in medical physics and which the categories were selected. The largest num-
vestibular disorders. The 19 physicians specialized in ber of categories was selected from the ICF compo-
neurology, otolaryngology, audiology, psychiatry, and nent Activities and Participation (40). Twenty-five cat-
oto-neurology. egories were selected from the component Body Func-
 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders 265

Table 3
International Classification of Functioning, Disability and Health (ICF) – Categories of the component Activities and Participation included in
the Vertigo Comprehensive Core Set. Vote indicates the stage of the process at which a category was selected (votes A and B were made in the
working groups, vote C was made in the final plenary session). The categories marked with X were included in the Brief Core Set
ICF Category description Vote Brief Core Set
Chapter: Learning and applying knowledge
d110 Watching A
d115 Listening C
d160 Focusing attention A
d166 Reading A
Chapter: General tasks and demands
d220 Undertaking multiple tasks A
d230 Carrying out daily routine A X
d240 Handling stress and other psychological demands A
Chapter: Communication
d350 Conversation C
d360 Using communication devices and techniques B
Chapter: Mobility
d410 Changing basic body position A X
d415 Maintaining a body position A X
d420 Transferring oneself C
d430 Lifting and carrying objects B
d445 Hand and arm use C
d450 Walking A X
d455 Moving around A X
d460 Moving around in different locations A X
d465 Moving around using equipment A
d469* Walking and moving, other specified and unspecified C X
d470 Using transportation A
d475 Driving A X
Chapter: Self-care
d510 Washing oneself B
d540 Dressing B
Chapter: Domestic life
d620 Acquisition of goods and services B
d630 Preparing meals B
d640 Doing housework A X
d650 Caring for household objects B
d660 Assisting others B
Chapter: Interpersonal interactions and relationships
d740 Formal relationships B
d750 Informal social relationships B
d760 Family relationships B
d770 Intimate relationships B
Chapter: Major life areas
d825* Vocational training C
d830* Higher education C
(d840–d859) Chapter: Work and employment A X
d845 Acquiring, keeping and terminating a job A
d850 Remunerative employment A
d855 Non-remunerative employment B
Chapter: Community, social and civic life
d910 Community life A
d920 Recreation and leisure A
∗ Categories introduced in the final plenary session.

tions, six from Body Structures, and 29 from Environ- Walking and moving, other specified and unspecified
mental Factors. In the second plenary session (Vote d469). One category had been dropped in Vote A but
C), participants proposed and voted on three additional was reintroduced by Vote C (Societal attitudes e460).
categories to be included in the comprehensive set that The chapters with the highest number of categories
had not been proposed initially by the preparatory stud- selected for the Comprehensive ICF Core Set were
ies (Vocational training d825, Higher Education d830, Mental functions (8) and Sensory functions (8) from
266 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders

Table 4
International Classification of Functioning, Disability and Health (ICF) – Categories of the component Environmental Factors included in the
Vertigo Comprehensive Core Set. Vote indicates the stage of the process at which a category was selected (votes A and B were made in the
working groups, vote C was made in the final plenary session). The categories marked with X were included in the Brief Core Set
ICF Category description Vote Brief Core Set
Chapter: Products and technology
e110 Products or substances for personal consumption A X
e115 Products and technology for personal use in daily living B
e120 Products and technology for personal indoor and outdoor mobility and transportation B X
e125 Products and technology for communication B
e150 Design, construction and building products and technology of buildings for public use B
e155 Design, construction and building products and technology of buildings for private use A
Chapter: Natural environment and human-made changes to environment
e240 Light B X
e250 Sound A
e255 Vibration C
Chapter: Support and relationships
e310 Immediate family A X
e315 Extended family B
e320 Friends B
e325 Acquaintances, peers, colleagues, neighbours and community members A
e330 People in positions of authority B
e340 Personal care providers and personal assistants C
e355 Health professionals A X
Chapter: Attitudes
e410 Individual attitudes of immediate family members A
e415 Individual attitudes of extended family members B
e420 Individual attitudes of friends B
e430 Individual attitudes of people in positions of authority A
e440 Individual attitudes of personal care providers and personal assistants C
e445 Individual attitudes of strangers B
e450 Individual attitudes of health professionals A
e460 Societal attitudes A
Chapter: Services, systems and policies
e515 Architecture and construction services, systems and policies B
e540 Transportation services, systems and policies A
e570 Social security services, systems and policies B
e580 Health services, systems and policies A X
e590 Labour and employment services, systems and policies A

the component Body Functions, Mobility (12) from the sulted in the Brief and Comprehensive ICF Core Set
component Activities and Participation, and Attitudes for vertigo, dizziness and balance disorders. This ap-
(8) from the component Environmental Factors. proach is new insofar as it gives a comprehensive pic-
The Brief ICF Core Set contained 29 categories, nine ture of the components of disability and impact of dis-
from the component Body Functions, four from the ease on functioning based on the unifying framework
component Body Structures, 10 from the component and model of the ICF.
Activities and Participation, and six categories from From the component Body Functions, not surprising-
the component Environmental Factors. The Brief ICF ly, categories from the chapters Mental functions and
Core Set is shown in Table 5. Figures 1 a-d show the Sensory functions were emphasized. Attention, mem-
results of the ranking process for all components along ory and perceptual deficits are likely to be associated
with the final cut-off. The Brief ICF Core Set contained with vestibular disease [22]. The selection of energy
categories that accounted for 82% of the total rank and drive functions and emotional functions is in ac-
score sum for the component Body Functions, 75% for cordance with the literature on psychological problems
Body Structures, 64% for Activities and Participation in persons with vertigo and dizziness, e.g., depression
and 52% for Environmental Factors. and anxiety [25,26]. The impact of the sudden on-
set of vertigo during the night on the quality of sleep
4. Discussion was discussed and regarded as relevant by conference
participants. Among sensory functions, the category
A nominal consensus process based on expert knowl- Functions of structures adjoining the eye (b215) was
edge and integrating results of preparatory studies re- included specifically to account for nystagmus. The
 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders 267

Table 5
International Classification of Functioning, Disability and Health (ICF) – Categories of the Brief Vertigo Core Set. Vote indicates the stage of the
process at which a category was selected (votes A and B were made in the working groups, vote C was made in the final plenary session)
ICF Category description Vote
b152 Emotional functions A
b156 Perceptual functions A
b210 Seeing functions A
b215 Functions of structures adjoining the eye A
b230 Hearing functions B
b235 Vestibular functions A
b240 Sensations associated with hearing and vestibular function A
b260 Proprioceptive function A
b770 Gait pattern functions A
d230 Carrying out daily routine A
d410 Changing basic body position A
d415 Maintaining a body position A
d450 Walking A
d455 Moving around A
d460 Moving around in different locations A
d469* Walking and moving, other specified and unspecified C
d475 Driving A
d640 Doing housework A
(d840–d859) Work and employment A
e110 Products or substances for personal consumption A
e120 Products and technology for personal indoor and outdoor mobility and transportation B
e240 Light B
e310 Immediate family A
e355 Health professionals A
e580 Health services, systems and policies A
s110 Structure of brain A
s120 Spinal cord and related structures A
s260 Structure of inner ear A
s410 Structure of cardiovascular system A
∗ Categories introduced in the final plenary session.

Fig. 1A. Ranking results of the component Body Functions. The Y-Axis indicates the sum of ranks assigned to the respective category. The
dashed line indicates the final cut-off for the Brief ICF Core Set. Categories that received no ranks are not shown (b144).
268 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders

Fig. 1B. Ranking results of the component Body Structures. The Y-Axis indicates the sum of ranks assigned to the respective category. The
dashed line indicates the final cut-off for the Brief ICF Core Set.

Fig. 1C. Ranking results of the component Activities and Participation. The Y-Axis indicates the sum of ranks assigned to the respective category.
The dashed line indicates the final cut-off for the Brief ICF Core Set. Categories that received no ranks are not shown (d115, d360, d540, d650,
d750, d825, d845).

category sensation of pain was included to adress neck agreement about many Body Functions and most Body
pain. Touch functions were interpreted as relating to Structures already given in Vote A supports the face
proprioception and balance and therefore included. validity of those categories.
The selected categories of the component Body The broad coverage of categories from the compo-
Structures refer to peripheral vestibular, central nervous nent Activities and Participation demonstrates the im-
system and cardiovascular origin of disease. The high portance given to this component by most health pro-
 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders 269

Fig. 1D. Ranking results of the component Environmental Factors. The Y-Axis indicates the sum of ranks assigned to the respective category.
The dashed line indicates the final cut-off for the Brief ICF Core Set. Categories that received no ranks are not shown (e440).

fessionals. Specifically, the impact of vertigo on activ- The consensus process used here has potential lim-
ities of daily living is well described in the literature [6, itations. One concern in the beginning of the consen-
24], showing considerable consequence for social par- sus process was that a dissident opinion of one work-
ticipation and work [5]. To give an example, in a rep- ing group would not survive the plenary session. This,
resentative study, up to 20% of persons with vertigo however, proved to be one of the strengths of the pro-
reported avoiding leaving the house [18]. cess. An argument of a group that was strong and pro-
In total, 12 categories referring to mobility were in- vided enough evidence was able to turn around the deci-
cluded; the category Walking and moving, other speci- sion of the other participants. To give an example, Sen-
fied and unspecified (d469) was included after an ani- sations associated with the digestive system, specifical-
mated discussion. This category encompasses the com- ly nausea (b535) received 62% affirming votes in Vote
plex action of walking while turning the head, which A with two working groups being strongly in favour.
was mentioned as a triggering situation. Driving [8, After discussion this category fell to 7% affirmation
20], household activities and shopping [2] were includ- in Vote B, because this category was seen to represent
ed as essential activities most likely limited in persons
the gastrointestinal rather than the vestibular aspects of
with vertigo. Categories from the chapters Mobility
nausea and vomiting. Another potential limitation may
and Work and employment were mostly accepted with
have been the choice of experts. The organizers of the
Vote A on the level of the working groups. The block
conference took care in the selection of experts. Nev-
Work and employment (d840–d859) was unanimously
included along with three of the categories contained ertheless, not all world regions could be represented,
in that chapter. Vocational training (d825) and Higher and some areas of expertise may have been underrep-
education (d830) were proposed and included in Vote resented. Although the results have high face validity,
C. the ICF Core Set requires further testing and valida-
Although the environment itself is not amenable to tion. Creating a Brief ICF Core Set was straightforward
change by therapy, the Environmental Factors compo- concerning Body Functions and Body Structures, but
nent was considered as most important, either as a fa- decision on a reduction of the number of categories of
cilitating factor (e.g., products and technologies such the components Activities and Participation was more
as walking aids) or as triggers or barriers. The con- difficult. This is illustrated in Figs 1a, b, c, d. While
struction of buildings or the characteristics of natural the participants agreed in assigning high ranks to a few
surroundings [3] creating disorienting visual clues [21] categories from Body Functions, the ranks for Activi-
or the movement of large objects, disorienting lights or ties and Participation and Environmental Factors were
sounds [4] were mentioned as examples. more widespread. It remains to be determined empiri-
270 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders

cally if this Brief ICF Core Set captures the most salient Michael Strupp, Michael Von Brevern, Miriam Wel-
issues of vertigo and dizziness. gampola, Susan Whitney.
Other scales examining functioning in vertigo and Many thanks to group assistants and team: Verena
dizziness are available [5,7,13,14,16,17,25]. Recently, Brümmer, Uli Fischer, Gabriele Mayer, René Mittrach,
a scale based on the Activities and Participation com- Melissa Selb, Ralf Strobl.
ponent of the ICF was proposed [1]. These measures This project was supported by funds from the Ger-
are usually more restricted in their aims and scope than man Federal Ministry of Education and Research un-
the effort of the ICF Core Set development reported der the Grant code 01 EO 0901. The authors bear full
here. However, it has to be kept in mind that ICF Core responsibility for the content of this publication.
Sets are not measures. They are list of codes indicat-
ing what to measure but not how to measure. How References
to select appropriate measurement instruments based
on ICF Core Sets requires several decisions, e.g. on [1] A.A. Alghwiri, S.L. Whitney, C.E. Baker, P.J. Sparto, G.F.
the level of detail (single item or item battery), on the Marchetti, J.C. Rogers and J.M. Furman, The development
and validation of the vestibular activities and participation
addressee (self-report by patient or clinical assessment measure. Arch Phys Med Rehabil 93 (2012), 1822-1831.
by health professional), or on the desired psychometric [2] D.C. Beidel and F.B. Horak, Behavior therapy for vestibular
qualities (sensitivity for change, discrimination). New rehabilitation, J Anxiety Disord 15 (2001), 121-130.
measures can be created by modifying or adding items [3] T. Brandt, F. Arnold, W. Bles and T.S. Kapteyn, The mecha-
nism of physiological height vertigo. I. Theoretical approach
to existing measures. New items can be written based and psychophysics, Acta Otolaryngol 89 (1980), 513-523.
on ICF categories. Some categories, e.g., from the [4] A.M. Bronstein, Vision and vertigo: Some visual aspects of
component Body Functions, will have to be expand- vestibular disorders, J Neurol 251 (2004), 381-387.
ed for more detailed assessment; some will have to be [5] A.M. Bronstein, J.F. Golding, M.A. Gresty, M. Mandala, D.
Nuti, A. Shetye and Y. Silove, The social impact of dizziness
compressed for reasons of feasibility. For the purpose in London and Siena, J Neurol 257 (2010), 183-190.
of item writing, the participants of this consensus con- [6] H. Cohen, Vestibular rehabilitation reduces functional disabil-
ference recommended creation of blocks of important ity, Otolaryngol Head Neck Surg 107 (1992), 638-643.
but similar categories such as the categories from the [7] H.S. Cohen and K.T. Kimball, Development of the vestibular
disorders activities of daily living scale, Arch Otolaryngol
chapter Attitudes. Despite content validity, new items Head Neck Surg 126 (2000), 881-887.
and new scales based on the ICF Core Set for vertigo [8] H.S. Cohen, J. Wells, K.T. Kimball and C. Owsley, Driving
still have to undergo extensive testing to prove their disability and dizziness, J Safety Res 34 (2003), 361-369.
[9] M. Duracinsky, I. Mosnier, D. Bouccara, O. Sterkers and O.
reliability and validity clinically. Chassany, Literature review of questionnaires assessing verti-
In conclusion, the ICF Core Set for vertigo and dizzi- go and dizziness, and their impact on patients’ quality of life,
ness provides health professionals with a framework to Value Health 10 (2007), 273-284.
assess patients comprehensively in inpatient and ambu- [10] E. Grill, T. Ewert, S. Chatterji, N. Kostanjsek and G. Stucki,
ICF Core Sets development for the acute hospital and early
latory settings. We envision that the ICF Core Set will post-acute rehabilitation facilities, Disabil Rehabil 27 (2005),
be used to evaluate the contents of existing measures 361-366.
and to create new measures of functioning. ICF Core [11] E. Grill, M. Quittan, V. Fialka-Moser, M. Muller, R. Strobl, N.
Sets create patient-relevant measures and outcomes that Kostanjsek and G. Stucki, Brief ICF Core Sets for the acute
hospital, J Rehabil Med 43 (2011), 123-130.
can be used as evidence for the success of treatments. [12] E. Grill, R. Strobl, M. Muller, M. Quittan, N. Kostanjsek and
G. Stucki, ICF Core Sets for early post-acute rehabilitation
facilities, J Rehabil Med 43 (2011), 131-138.
Acknowledgement [13] V. Honrubia, T.S. Bell, M.R. Harris, R.W. Baloh and L.M.
Fisher, Quantitative evaluation of dizziness characteristics and
impact on quality of life, Am J Otol 17 (1996), 595-602.
We are most grateful for the contributions made [14] G.P. Jacobson and C.W. Newman, The development of the
by the following experts attending the conference: Dizziness Handicap Inventory, Arch Otolaryngol Head Neck
Alexandre Bisdorff, Heike Christmann, Michael Fet- Surg 116 (1990), 424-427.
[15] A. Kurre, C.H. Bastiaenen, C.J. van Gool, T. Gloor-Juzi, E.D.
ter, Mariella Graziano, Christoph Helmchen, Klaus de Bruin and D. Straumann, Exploratory factor analysis of the
Jahn, Joanna Jen, Ji Soo Kim, Herman Kingma, Dizziness Handicap Inventory (German version), BMC Ear
Sarah Kirby, Andreas Lauenroth, Thomas Lempert, Nose Throat Disord 10 (2010), 3.
[16] A.E. Morris, M.E. Lutman and L. Yardley, Measuring out-
José Antonio Lopez-Escamez, Eva-Maj Malmström,
come from Vestibular Rehabilitation, Part I: Qualitative devel-
David Newman-Toker, Daniele Nuti, Holger Rambold, opment of a new self-report measure, Int J Audiol 47 (2008),
Thomas Sierla, Jeffrey Staab, Dominik Straumann, 169-177.
 E. Grill et al. / ICF Core Set for patients with vertigo, dizziness and balance disorders 271

[17] A.E. Morris, M.E. Lutman and L. Yardley, Measuring out- [22] P.F. Smith, Y. Zheng, A. Horii and C.L. Darlington, Does
come from vestibular rehabilitation, part II: refinement and vestibular damage cause cognitive dysfunction in humans? J
validation of a new self-report measure, Int J Audiol 48 (2009), Vestib Res 15 (2005), 1-9.
24-37. [23] World Health Organisation (WHO), International Classifica-
[18] H.K. Neuhauser, A. Radtke, M. von Brevern, F. Lezius, M. tion of Functioning, Disability and Health: ICF., WHO, Gene-
Feldmann and T. Lempert, Burden of dizziness and vertigo in va, 2001.
the community, Arch Intern Med 168 (2008), 2118-2124. [24] L. Yardley, B. Dibb and G. Osborne, Factors associated with
[19] H.K. Neuhauser, M. von Brevern, A. Radtke, F. Lezius, M. quality of life in Meniere’s disease, Clin Otolaryngol Allied
Feldmann, T. Ziese and T. Lempert, Epidemiology of vestibu- Sci 28 (2003), 436-441.
lar vertigo: A neurotologic survey of the general population, [25] L. Yardley, E. Masson, C. Verschuur, N. Haacke and L. Lux-
Neurology 65 (2005), 898-904. on, Symptoms, anxiety and handicap in dizzy patients: devel-
[20] N.G. Page and M.A. Gresty, Motorist’s vestibular disorien- opment of the vertigo symptom scale, J Psychosom Res 36
tation syndrome, J Neurol Neurosurg Psychiatry 48 (1985), (1992), 731-741.
729-735. [26] L. Yardley, C. Verschuur, E. Masson, L. Luxon and N. Haacke,
[21] M.S. Redfern, L. Yardley and A.M. Bronstein, Visual influ- Somatic and psychological factors contributing to handicap in
ences on balance, J Anxiety Disord 15 (2001), 81-94. people with vertigo, Br J Audiol 26 (1992), 283-290.