patients' experience post-lumbar fusion regarding back problems, recovery and expectations in...

RESEARCH PAPER

Patients’ experience post-lumbar fusion regarding back problems,recovery and expectations in terms of the international classificationof functioning, disability and health

ALLAN D. ABBOTT1,2, RUNE HEDLUND3 & RAIJA TYNI-LENNE1

1Department of Physical Therapy, Karolinska University Hospital, Stockholm 14186, Sweden, 2Department of Clinical

Science, Intervention and Technology, Division of Orthopaedics, Karolinska University Hospital, Karolinska Institute,

Stockholm 14186, Sweden, 3Department of Orthopaedics, Institute for Clinical Science, University of Gothenburg, Gothenburg

41345, Sweden

Accepted October 2010

AbstractPurpose. To describe within the context of the International Classification of Functioning, Disability and Health (ICF),patient’s experiences post-lumber fusion regarding back problems, recovery and expectations of rehabilitation and tocontrast with the content of outcome measures and the ICF low back pain (LBP) core sets.Methods. The study has a cross-sectional and retrospective design and involves 20 lumbar fusion patients. Using the ICF,qualitative content analysis of semi-structured interviews 3–6 months post-surgery was performed. This was compared withthe ICF related content of the Oswestry Disability Index (ODI), Medical Outcome Study Short Form 36 (SF-36), EuropeanQuality of Life Questionnaire (EQ5D) and the ICF LBP core sets.Results. Patient’s experiences were most frequently linked to psychological, sensory, neuromusculoskeletal and movementrelated body function chapters of the ICF. The most frequently linked categories of activity and participation were mobility,domestic activities, family relationships, work, recreation and leisure. Environmental factors frequently linked were the use ofanalgesics, walking aids, family support, social security systems, health care systems and labour market employment services.Conclusions. This study highlights important ICF related aspects of patient’s experiences post-lumber fusion. The use of thecomprehensive ICF core sets is recommended in conjunction with ODI, SF-36 and the EQ5D for a broader analysis ofpatient outcomes post-lumbar fusion.

Keywords: ICF, spinal fusion, lumbar fusion, back

Introduction

An increasing number of patients with chronic low

back pain (CLBP) are treated with surgical interven-

tions such as spinal fusion [1–3]. There has been

little attention paid to the early post-operative

management of these patients. Results from a recent

randomised controlled trial (RCT) [4] suggest that

for patients operated with lumbar fusion, post-

operative rehabilitation focusing on cognition, beha-

viour and motor control improve functional ability,

psychological and work-related factors significantly

more than rehabilitation focusing on strength and

conditioning.

Intervention research predominately uses quanti-

tative methods in the form of physical testing and

questionnaires for the objective measurement of

pain, disability and quality-of-life-related outcomes.

However, since the emergence of the biopsychosocial

model of health care, qualitative methods have

received renewed interests due to the importance of

investigating the patient’s subjective perspectives

and views. Therefore, a complementing rather than

dichotomised view of interaction between qualitative

and quantitative methods has developed [5]. This

has advocated a ‘new gold standard’ of clinical

research, the multi-method RCT where the research

question connects quantitative methods providing

Correspondence: Dr. Allan D. Abbott, Department of Physical Therapy, Karolinska University Hospital, Stockholm 14186, Sweden. Email:

[email protected]

Disability and Rehabilitation, 2011; 33(15–16): 1399–1408

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.

DOI: 10.3109/09638288.2010.533240

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measurement and qualitative methods addressing

issues of context and meaning [6].

Several different methods can be used to provide

qualitative descriptions of patient’s experiences of

their condition and treatments. Grounded theory

is used when the aim is to generate theory. Both

qualitative content analysis and phenomenology can

lead to hierarchical thematic categories that emerge

from the data; however, they are arrived at by

different means. The phenomenological researcher’s

approach to data analysis is based on theory and an

understanding of the phenomenon. The approach

to data analysis taken by content analysis research-

ers is the application of a priori concepts and

constructs [6].

The International Classification of Functioning,

Disability and Health (ICF) is a helpful tool for

content analysis [7]. The ICF is also helpful in mixed

methods research providing a common terminology

for analysing and linking the content of quantitative

and qualitative measures. The first level classifica-

tions in the ICF are coded with a letter referring to

the different components where b¼ body functions

and s¼ body structures, d¼ activities and participa-

tion, e¼ environmental factors and p¼ personal

factors. Several components can be further coded

with a number referring to second level chapters,

third level categories and fourth level sub-categories

(Figure 1).

The primary aim of this study is to describe within

the context of the ICF, the patient’s experiences

post-lumber fusion regarding back problems, post-

operative recovery and expectations of rehabilitation.

A secondary aim of the study is to contrast the ICF

content of the patient’s experiences and expectations

to the item content of questionnaires commonly used

to measure outcome in spinal surgery and the ICF

core sets for LBP. The significance of this study is

that it sheds light on the patient’s subjective

experiences and the utility of the ICF in multi-

method outcome research for surgical and rehabili-

tative interventions in the spinal orthopaedic field.

Materials and methods

Participants

Participants were recruited through Karolinska Uni-

versity Hospital’s Orthopaedic Clinic in Huddinge,

Sweden, between 2005 and 2007. Patients were

already participants in an RCT evaluating the

effectiveness of early post-operative rehabilitation

methods after lumbar fusion surgery [4]. In the

study, one group received psychomotor therapy

focusing on cognition, behaviour and motor control

in comparison to another group who received

exercise therapy focusing on strength and condition-

ing [4]. The effectiveness of the two forms of

rehabilitation were measured longitudinally in terms

of pain related functional disability, pain intensity,

health related quality of life (HRQOL), functional

self-efficacy, back pain outcome expectancy, fear of

movement/(re)injury and pain catastrophising. The

study included patients aged between 18 and 65

years, with competency in the Swedish language and

a history of back pain and/or sciatica exceeding 12

months for which conservative treatment had failed

to improve. Furthermore, patients had a primary

diagnosis of spinal stenosis, degenerative or isthmic

spondylolisthesis or degenerative disc disease and

were selected for lumbar fusion surgery with or

without decompression or instrumentation. The

study excluded patients with previous lumbar fusion,

rheumatoid arthritis and ankylosing spondylitis. The

demographic characteristics of the recruited patients

are presented in Table I.

Procedure

Patients returning to Karolinska University Hospi-

tal’s Orthopaedic Clinic for a 3-month post-surgical

follow-up during the period of May 2006 to May

2007 received both verbal and written information of

the interview study. According to Creswell [8]

interviews of up to 10 patients are needed to provide

substantial data for good qualitative research. We

planned to recruit a total of 20 patients, including 10

patients, 5 males and 5 females from each of the

psychomotor therapy and the exercise therapy post-

operative rehabilitation groups in the RCT [4]. The

ethics committee for medical research in Stockholm

health region approved the study.Figure 1. The International classification of functioning, disability

and health applied according to WHO [7].

1400 A. D. Abbott et al.

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Instruments

A semi-structured interview guide listing open-

ended question was used when interviewing the

patients. The hypothetical formulation of the ques-

tions was aimed at identifying all possible ICF

components in the patient’s experiences of back

problems and of post-operative recovery and in the

expectations of rehabilitation. To be open with the

informant’s agenda, planned and unplanned probing

questions were used [9,10]. Interviews were audio

taped with the participant’s consent and concluded

when all areas of interest had been discussed. The

following questions were used:

1) How do you think your back problems

influenced your life before the operation?

Probe – How did your back problems

influence your family life?


influence your working life?


influence physical activities?

2) How do you think your back problems

influence your life now?

Probe – How do your back problems influ-

ence your family life?


ence your working life?


ence physical activities?

3) Describe your experience of recovery after

surgery?

Probe – Related to family life?

Probe – Related to working life?

Probe – Related to physical activities?

4) What are your expectations with the outcome

of rehabilitation after surgery?

Probe – Related to family life?

Probe – Related to working life?

Probe – Related to physical activities?

The content of questionnaires commonly used to

measure outcome in lumbar fusion surgery in the

Swedish National Spine Register [11] and inter-

nationally [12] were also investigated in this study.

The Oswestry Disability Index (ODI) 2.0 is a LBP

specific quality of life measure. It contains 10

questions each with 5 possible response categories

assessing the extent to which LBP limits activities of

daily living [13,14]. The Medical Outcome Study

Short Form 36 (SF-36) is a generic measure of

quality of life. It contains 36 items assessing physical

functioning, role limitation caused by physical

health problems, role limitations caused by emo-

tional problems, social functioning, emotional well-

being, energy and fatigue, pain, general health

perceptions, emotional wellbeing and change in

perceived health [15]. The European Quality of

Life Questionnaire (EQ5D) is another generic

measure of quality of life. Using the EQ5D,

respondents can classify there own health status in

five dimensions including mobility, self-care, usual

activities, pain/discomfort and anxiety/depression

within three levels including no problems, moderate

problems and severe problems [16].

The content of the ICF comprehensive and brief

core sets for LBP were also considered [17]. The 78

categories of the comprehensive LBP core set

consists of 19 from body functions, 5 from body

structures, 29 from activities and participation and

25 from environmental factors. The 35 categories of

the brief LBP core set consists of 10 from body

functions, 3 from the component body structures, 12

from activities and participation and 10 from

environmental factors.

Data analysis

In this study, content analysis was used due to the

ability to apply priori concepts [18,19]. The units of

Table I. Baseline demographic characteristics of patients.

Variable

Sex

Male 10

Female 10

Age (mean in years+SD) 53.7+9.1

Back pain duration

Less than 3 months 0

3–12 months 3

12–24 months 3

More than 24 months 14

Sciatica duration

Less than 3 months 2

3–12 months 2

12–24 months 5

More than 24 months 11

Work status

Employed 15

Unemployed 1

Retired 1

Full-time disability pension 3

Sickness leave

None 8

Full-time 8

Sick leave duration (mean in months+SD) 9.2+7.3

Analgesics consumption

None 1

Sometimes 9

Frequently 10

Diagnosis

Spinal stenosis 7

Degenerative Spondylolisthesis 4

Isthmic Spondylolisthesis 1

Degenerative disc disease 8

Patients’ experience post-lumbar fusion 1401

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analysis were the interview transcription, and the

Swedish versions of the ODI, SF-36 and EQ5D

questionnaires. The ICF was applied to identify and

code meaningful units.

Analysis was performed in the following steps:

1) The interviews transcriptions and the ques-

tionnaires were read in their entirety by the

main author, two times to obtain an overall

picture.

2) Using the content area of answers in the

interview and the content of questionnaires,

meaning units were constructed where words,

sentences or paragraphs could be related to

the ICF components including body functions

and structures, activities and participation,

environmental and personal factors.

3) ICF linking rules were used to code meaning

units [20]. Diversion from the linking rules

included the linking of meaning units into first

and second level ICF categories rather than

further coding into third and fourth levels of

the ICF. This was performed to minimise the

complexity of the analysis for simpler descrip-

tion and discussion of results. Two of the

authors independently coded the meaning

units. Both were physiotherapists with post-

graduate training and practical experience in

qualitative content analysis using the ICF. In

the case of poor inter-rater reliability between

the two independent coders, a third rater was

planned to independently code the meaning

units to provide a comparative test of relia-

bility. The ICF definitions used in this study

are from the Swedish version of the ICF

handbook [21] and are also available on

WHO’s website www.who.org/classifications/

icfbrowser.

The degree of agreement between the two health

professionals was calculated at the component, first

and second ICF levels using Krippendorff’s alpha.

Krippendorff’s alpha has been advocated as the

standard reliability measure for content analysis.

Unlike other reliability measures, it can generalise

across scales of measurement, can be used with any

number of observers with or without missing data,

and it satisfies all of the important criteria for a good

measure of reliability [22]. Krippendorff’s alpha

coefficient ranges from 0–1 where 1 indicates perfect

agreement and 0 indicating no agreement. Bootstrap

resampling (n¼ 1000) of the observations in the

sample was used to attain 95% bootstrapped con-

fidence intervals indicating the precision of the

estimated Krippendorff alpha statistic. Statistical

Package for Social Sciences Version 17 (SPSS Inc.,

Chicago, IL, USA) was used for statistical tests along

with an SPSS KALPHA macro downloaded from

www.comm.ohio-state.edu/ahayes/macros.htm [22].

Results

A total of 35 patients were informed of the interview

study and 20 agreed to participate and gave written

consent before participating. Reported reasons for

the 15 patients not wanting to participate in the study

were a lack of time or interest in participating in

more research than the original demands of the

RCT. Tables II–IV show the first and second level

ICF categories found in the content analysis of

interviews and questionnaires such as the ODI, SF-

36 and the EQ5D. The tables also display the

comprehensive and brief core sets for LBP for

comparison to the content of interviews and the

questionnaires. Inter-rater reliability statistics be-

tween two independent raters of interview meaning

units at the component, first and second levels of the

ICF are shown in Table V.

A total of 844 meaning units were identified in the

interview manuscript and 867 concepts could be

linked to 94 different ICF categories. Of the concepts

that could be linked to the ICF, 276 were body

functions, 31 were body structures, 464 were related

to activities and participation and 88 were environ-

mental factors. An additional six concepts were

related to personal factors associated with coping

style, beliefs and locus of control while another two

were not definable physical health concepts.

When patients were asked how they think their

back problems influenced their life before the

operation, their responses covered 54 categories of

the ICF. These 54 categories consisted of 11 (20%)

body functions, 3 (6%) body structures, 29 (54%)

activities and participation and 11 (20%) environ-

mental factors. When patients were asked how they

think their back problems influence their life in the

present, their responses covered 50 ICF categories

consisting of 18 (36%) body functions, 3 (6%) body

structures, 19 (38%) activities and participation and

10 (20%) environmental factors. When patients were

asked to describe their experience of recovery after

the surgery, their responses covered 45 ICF cate-

gories consisting of 15 (33%) body functions, 4 (9%)

body structures, 19 (42%) activities and participation

and 7 (16%) environmental factors. When patients

were asked what their expectations were with the

outcome of rehabilitation after surgery, their re-

sponses covered 49 ICF categories consisting of 16

(33%) body functions, 5 (10%) body structures, 21

(43%) activities and participation and 7 (14%)

environmental factors.

A total of 116, 43 and 25 relevant concepts at the

question item and response levels of the ODI, SF-36


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http://www.who.org/classifications/icfbrowser

http://www.who.org/classifications/icfbrowser

http://www.comm.ohio-state.edu/ahayes/macros.htm

Tab

leII

.C

om

par

iso

ns

bet

wee

nin

terv

iew

,q

ues

tio

nn

aire

and

LB

Pco

rese

tco

nte

nt

anal

ysis

inte

rms

of

ICF

cate

go

ryfr

equ

enci

esfo

rth

eco

mp

on

ents

bo

dy

fun

ctio

ns

and

stru

ctu

res.

1)

Ho

wd

oyo

uth

ink

you

rb

ack

pro

ble

ms

infl

uen

ced

you

rlife

bef

ore

the

op

erat

ion

?

2)

Ho

wd

oyo

uth

ink

you

rb

ack

pro

ble

ms

infl

uen

ceyo

ur

life

no

w?

3)

Des

crib

eyo

ur

exp

erie

nce

of

reco

very

afte

r

surg

ery?

4)

Wh

atar

eyo

ur

exp

ecta

tio

ns

wit

hth

e

ou

tco

me

of

reh

abili-

tati

on

afte

rsu

rger

y?O

DI

SF

-36

EQ

-5D

ICF

core

sets

LB

P

Bri

efIC

F

core

sets

LB

P

bB

OD

YF

UN

CT

ION

S

b1

26

Tem

per

amen

tan

dp

erso

nal

ity

fun

ctio

ns

34

84

1

b1

30

En

ergy

and

dri

vefu

nct

ion

s1

310

15

31

1

b1

34

Sle

epfu

nct

ion

s1

22

71

1

b1

52

Em

oti

on

alfu

nct

ion

s1

710

12

51

14

11

b1

60

Th

ou

gh

tfu

nct

ion

s1

12

1

b1

64

Hig

her

-lev

elco

gn

itiv

efu

nct

ion

s5

21

b1

80

Exp

erie

nce

of

self

and

tim

e

fun

ctio

ns

11

1

b2

60

Pro

pri

oce

pti

vefu

nct

ion

s1

11

1

b2

70

Sen

sory

fun

ctio

ns

rela

ted

to

tem

per

atu

rean

do

ther

stim

uli

53

12

b2

80

Sen

sati

on

of

pai

n4

225

13

15

49

42

11

b2

89

Sen

sati

on

of

pai

n,

oth

ersp

ecifi

ed

and

un

spec

ified

2

b4

55

Exer

cise

tole

ran

cean

dfu

nct

ion

s1

11

b5

30

Wei

gh

tm

ain

ten

ance

fun

ctio

ns

11

b6

20

Uri

nat

ion

fun

ctio

ns

11

b6

40

Sex

ual

fun

ctio

ns

11

b7

10

Mo

bilit

yo

fjo

int

fun

ctio

ns

22

11

b7

15

Sta

bilit

yof

join

tfu

nct

ion

s1

1

b7

20

Mo

bilit

yo

fb

on

efu

nct

ion

s1

b7

30

Mu

scle

po

wer

fun

ctio

ns

32

31

1

b7

35

Mu

scle

ton

efu

nct

ion

s1

1

b7

40

Mu

scle

end

ura

nce

fun

ctio

ns

31

21

1

b7

50

Mo

tor

refl

exfu

nct

ion

s1

11

b7

55

Invo

lun

tary

mo

vem

ent

reac

tio

n

fun

ctio

ns

12

1

b7

70

Gai

tp

atte

rnfu

nct

ion

s5

41

1

b7

80

Sen

sati

on

sre

late

dto

mu

scle

san

d

mo

vem

ent

fun

ctio

ns

56

23

1

sB

OD

YS

TR

UC

TU

RE

S

s12

0S

pin

alco

rdan

dre

late

dst

ruct

ure

s2

11

11

1

s73

0S

tru

ctu

reo

fu

pp

erex

trem

ity

1

s74

0S

tru

ctu

reo

fp

elvi

cre

gio

n1

s75

0S

tru

ctu

reo

flo

wer

extr

emit

y2

11

11

s76

0S

tru

ctu

reo

ftr

un

k7

33

51

11

s77

0A

dd

itio

nal

mu

scu

losk

elet

alst

ruc-

ture

sre

late

dto

mo

vem

ent

11

11


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Tab

leII

I.C

om

par

iso

ns

bet

wee

nin

terv

iew

,q

ues

tio

nn

aire

and

LB

Pco

rese

tco

nte

nt

inte

rms

of

ICF

cate

go

ryfr

equ

enci

esfo

rac

tivi

ties

and

par

tici

pat

ion

.

1)

Ho

wd

oyo

uth

ink

you

rb

ack

pro

ble

ms

infl

uen

ced

you

rlife

bef

ore

the

op

erat

ion

?

2)

Ho

wd

oyo

uth

ink

you

rb

ack

pro

ble

ms

infl

uen

ceyo

ur

life

no

w?

3)

Des

crib

eyo

ur

exp

erie

nce

so

f

reco

very

afte

r

surg

ery?

4)

Wh

atar

eyo

ur

exp

ecta

tio

ns

wit

hth

e

ou

tco

me

of

reh

abili-

tati

on

afte

rsu

rger

y?O

DI

SF

-36

EQ

-5D

ICF

core

sets

LB

P

Bri

efIC

F

core

sets

LB

P

dA

CT

IVIT

IES

AN

DP

AR

TIC

IPA

TIO

N

d2

Gen

eral

task

san

dd

eman

ds

11

1

d2

10

Un

der

takin

ga

sin

gle

task

11

2

d2

30

Car

ryo

ut

dai

lyro

uti

ne

21

21

d2

40

Han

dlin

gst

ress

and

oth

erp

sych

olo

gic

al

dem

and

s

21

1

d4

Mo

bilit

y1

d4

10

Ch

angin

gb

asic

bo

dy

po

siti

on

20

15

12

69

21

1

d4

15

Mai

nta

inin

ga

bo

dy

po

siti

on

59

44

61

1

d4

20

Tra

nsf

erri

ng

on

esel

f1

11

d4

30

Lif

tin

gan

dca

rryi

ng

ob

ject

s9

71

47

21

1

d4

45

Han

dan

dar

mu

se1

11

d4

50

Wal

kin

g2

32

51

51

06

32

11

d4

55

Mo

vin

gar

ou

nd

13

95

10

13

1

d4

60

Mo

vin

gar

ou

nd

ind

iffe

ren

tlo

cati

on

s1

32

21

d4

65

Mo

vin

gar

ou

nd

usi

ng

equ

ipm

ent

24

11

1

d4

70

Usi

ng

tran

spo

rtat

ion

37

17

1

d4

75

Dri

vin

g8

41

31

d4

98

Mo

bilit

y,o

ther

spec

ified

1

d5

self

-car

e1

11

d5

10

Was

hin

go

nes

elf

21

11

31

d5

30

To

ilet

ing

11

1

d5

40

Dre

ssin

g1

11

31

1

d6

Do

mes

tic

life

1

d6

20

Acq

uis

itio

no

fgo

od

san

dse

rvic

es2

21

1

d6

30

Pre

par

ing

mea

ls1

21

11

1

d6

40

Do

ing

ho

use

wo

rk5

31

22

11

1

d6

50

Car

ing

for

ho

use

ho

ldo

bje

cts

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and the EQ5D, respectively, were identified and

linked to the ICF. The ODI covered 2 (12,5%) body

function categories, 1 (6%) body structure category,

11 (69%) activities and participation categories and 2

(12,5%) environmental factor categories. The items

in the SF-36 covered 14 ICF categories consisting 3

(21%) body functions and 11 (81%) from activities

and participation. The items in the EQ5D covered 3

(19%) body function categories and 13 (81%) from

activities and participation. The item questions and

responses in the SF-36 and EQ5D did not contain

ICF categories from the body structures or environ-

mental factor components.

Discussion

Using content analysis of interview manuscripts, the

study identified the subjective experiences of the

patient’s post-lumbar fusion with regards to back

problems, recovery and expectations. The ICF was

useful in coding the content of interview manuscripts

and even in comparison to questionnaires such as the

ODI, SF-36 and the EQ5D. This provides a method

of data triangulation between this qualitative study

and the previously published RCT [4] analysing the

ODI, SF-36 and EQ5D related outcomes of

rehabilitative interventions post-lumbar fusion.

When patients post-lumbar fusion were inter-

viewed about their experiences with back problems,

recovery and expectations, the ICF body function

chapters that could be linked were psychological

functions (b1), sensory functions and pain (b2),

along with neuromusculoskeletal and movement-

related functions (b7). The most frequent of all 24

body function categories linked were pain sensation

(b280), emotional functions (b152), as well as energy

and drive functions (b130). Commonly used mea-

sures of outcome after lumbar fusion, such as the

ODI, SF-36 and EQ5D, also cover the body function

category pain sensation (b280). The SF-36 and the

EQ5D furthermore cover the body function category

emotional functions (b152) while the SF-36 also

covers energy and drive functions (b130). The

content of the ODI, SF-36 and the EQ5D therefore

correspond well with the most relevant body func-

tions experienced by patient’s post-lumbar fusion,

but lack the comprehensiveness of other relevant

categories in the ICF chapters of psychological

functions (b1), sensory functions and pain (b2),

along with neuromuscular and movement related

functions (b7) outlined in Table II.

The comprehensive ICF core sets for LBP

correspond well with the body function categories

relevant to the experiences of the patient’s post-

lumbar fusion. The ranking of the most frequently

linked body functions experienced by these patients

were also similar to the ranking of body function

categories chosen for the ICF brief core sets for LBP

[16]. This suggests the relevance and comprehen-

siveness of ICF core sets for LBP for monitoring

body functions in patients undergoing lumbar fusion

and can be recommended for use as an outcome

measure in conjunction with standardised measures

such as the ODI, SF-36 and EQ5D.

The most frequently linked body structures used

to describe the patient’s experiences post-lumbar

fusion regarding back problems, recovery and

expectations were structures of the trunk (s760),

structures of the lower extremity (s750) and spinal

cord and related structures (s120). In contrast to the

ODI which is a low back specific questionnaire

related to structures of the trunk (s760), the SF-36

and the EQ5D are generic and not focusing on

specific body structures. In comparison to the

comprehensive ICF core sets for LBP, structures of

the pelvic region (s740) were not linked to the

patient’s experiences post-lumbar fusion. The most

relevant body structures summarised in the brief ICF

core sets for LBP [16] were also relevant for the

patient’s post-lumbar fusion.

The patient’s experiences post-lumbar fusion

regarding back problems, recovery and expectations

were linked to 33 categories of activities and

participations. The most frequently linked categories

included changing and maintaining body position

(d410–d415), lifting and carrying objects (d430),

walking and moving around (d450–d465), using

transport (d470), driving (d475), acquisition of

goods and services (d620), preparing meals (d630),

doing house work (d640), caring for household

objects (d650), family relationships (d760) and

remunerative employment (d850), along with re-

creation and leisure (d950). These categories linked

to the ICF covered all categories of activities and

participation linked to the ODI, SF-36 and EQ5D.

Categories frequently linked to the patient’s experi-

ences not covered by the ODI items are remunera-

tive employment (d850), changing basic body

position (d410), family relationships (d760) and

caring for household objects (d650). The SF-36 also

did not cover the categories family relationships

Table V. Estimated Krippendorff alpha coefficient and boot-

strapped confidence intervals at the component, 1st and 2nd ICF

levels for the interview text content analysis procedure.

a BCI 95%

Component 0.991 (0.981 to 0.998)

Chapter (1st level) 0.988 (0.979 to 0.998)

Category (2nd level) 0.988 (0.979 to 0.998)

a, estimated Krippendorff alpha coefficient; BCI 95%, boot-

strapped 95% confidence interval for alpha.


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(d760), maintaining body position (d415), using

transportation (d470), driving (d475), preparing

meals (d630) and caring for household objects.

Similarly, the EQ5D lacks ICF categories related to

changing and maintaining body position (d410–

d415), moving around and using transportation

(d455–d475), acquisition of goods and services

(d620) and caring for household objects (d650).

Categories of activities and participation fre-

quently linked to the experiences of patients but

not included in the brief ICF core sets for LBP

include categories related to moving around and

the use of transportation (d455–d475), as well as

recreation and leisure (d920). The comprehensive

ICF core sets for LBP covered respective categories

of the activities and participation not covered by the

ODI, SF-36 and EQ5D and therefore may prove

useful as a complement in monitoring patient out-

comes post-lumbar fusion.

The patient’s experiences post-lumbar fusion

regarding back problems, recovery and expectations

were linked to 14 categories of environmental

factors. The most frequently linked environmental

factors were products for personal consumption

(e110) and for personal indoor and outdoor mobility

and transportation (e120), support and relationships

from the immediate family (e310), as well as services,

systems and policies for social security (e570), health

care (e580), labour and employment (e590). Out-

come measures such as the SF-36 and EQ5D did not

cover environmental factors where as the ODI could

be linked to products for personal indoor and

outdoor mobility and transportation (e120) as well

as support and relationships (e3). The comprehen-

sive ICF core sets covered all categories relevant for

patients post-lumbar fusion while the brief ICF core

sets for LBP lacked relevant ICF categories such as

personal indoor and outdoor mobility and transpor-

tation (e120) and labour and employment (e590).

Therefore, the comprehensive ICF core sets for LBP

could be a helpful supplement to the use of standard

outcome measures for more complete monitoring of

environmental factor of importance to the patient’s

post-lumbar fusion.

With regards to the inter-rater reliability of the

interview text meaning unit coding, the degree of

agreement between the two health professionals was

very high. The Krippendorff alpha measuring the

reliability of component level ICF coding between

two independent raters was 99.1% with only 4 of the

867 codes differing between raters. Furthermore,

Krippendorff’s alpha for coding at first and second

ICF levels was 98.8% with 5 out of 867 codes

differing between raters. The validity of the linking

process in this study could have been strengthened

by increasing the number of raters, especially from

different professional backgrounds.

In conclusion, this study highlights the importance

of psychological, sensory, neuromusculoskeletal and

movement related body functions described by

patient’s post-lumbar fusion. Aspects of mobility,

domestic activities, family relationships, work, re-

creation and leisure were also described as important

areas of activity and participation. Furthermore, the

use of analgesics, walking aids, family support, social

security systems, health care systems and labour

market employment services were described as

important environmental factors. The use of the

comprehensive ICF core sets is recommended in

conjunction with standard outcomes measure such as

the ODI, SF-36 and the EQ5D for a broad analysis of

HRQOL outcomes in patient’s post-lumbar fusion.

Acknowledgements

The authors thank the staff at the Karolinska

University Hospital’s Physiotherapy Department for

help with data collection. This study was funded by a

research grant obtained from the Health Care

Sciences Postgraduate School, Karolinska Institute,

to the first author.

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