Protocol for the development and validation of a Core Set for exercise-based rehabilitation of adults with multiple long-term conditions (multimorbidity) based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework

Fanuel M Bickton^{1

2}, James R Manifield^{3

4}, Felix Limbani¹, Justin Dixon^{5

6}, Anne E Holland^{7

8

9}, Rod S Taylor^{10

11}, Claire Calderwood^{5

12}, Walter Wittich¹³, Celia L Gregson^{5

14}, Martin Heine^{15

16}, Zahira Ahmed^{3

4}, Ronel Roos¹⁷, Sally J Singh^{3

4}; Africa Multimorbidity Alliance – Multimorbidity Rehabilitation Working Group

Affiliations

¹ Lung Health Research Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.
² Department of Rehabilitation Sciences, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi.
³ Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Centre (BRC)- Respiratory, University Hospitals of Leicester NHS Trust, National Institute for Health and Care Research (NIHR), Leicester, UK.
⁴ Department of Respiratory Sciences, University of Leicester, Leicester, UK.
⁵ The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe.
⁶ Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK.
⁷ Department of Respiratory and Sleep Medicine, Alfred Health, Melbourne, VIC, Australia.
⁸ School of Translational Medicine, Monash University, Melbourne, VIC, Australia.
⁹ Institute for Breathing and Sleep, Heidelberg, VIC, Australia.
¹⁰ MRC/CSO Social & Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
¹¹ Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
¹² Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
¹³ School of Optometry, Université de Montréal, Montreal, QC, Canada.
¹⁴ Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK.
¹⁵ Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
¹⁶ Institute of Sport and Exercise Medicine, Department of Exercise, Sport and Lifestyle Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
¹⁷ Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

PMID: 40400508
PMCID: PMC12093010
DOI: 10.1177/26335565251343923

Protocol for the development and validation of a Core Set for exercise-based rehabilitation of adults with multiple long-term conditions (multimorbidity) based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework

Fanuel M Bickton et al. J Multimorb Comorb. 2025.

. 2025 May 20:15:26335565251343923.

doi: 10.1177/26335565251343923. eCollection 2025 Jan-Dec.

Authors

Affiliations

¹ Lung Health Research Group, Malawi-Liverpool-Wellcome Programme, Blantyre, Malawi.
² Department of Rehabilitation Sciences, School of Life Sciences and Allied Health Professions, Kamuzu University of Health Sciences, Blantyre, Malawi.
³ Centre for Exercise and Rehabilitation Science, Leicester Biomedical Research Centre (BRC)- Respiratory, University Hospitals of Leicester NHS Trust, National Institute for Health and Care Research (NIHR), Leicester, UK.
⁴ Department of Respiratory Sciences, University of Leicester, Leicester, UK.
⁵ The Health Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe.
⁶ Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK.
⁷ Department of Respiratory and Sleep Medicine, Alfred Health, Melbourne, VIC, Australia.
⁸ School of Translational Medicine, Monash University, Melbourne, VIC, Australia.
⁹ Institute for Breathing and Sleep, Heidelberg, VIC, Australia.
¹⁰ MRC/CSO Social & Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
¹¹ Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.
¹² Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
¹³ School of Optometry, Université de Montréal, Montreal, QC, Canada.
¹⁴ Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK.
¹⁵ Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
¹⁶ Institute of Sport and Exercise Medicine, Department of Exercise, Sport and Lifestyle Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
¹⁷ Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.

PMID: 40400508
PMCID: PMC12093010
DOI: 10.1177/26335565251343923

Abstract

Background: Core outcome sets for people with multiple long-term conditions (multimorbidity) intervention studies offer an opportunity to compare data across studies and countries. However, a key research gap remains: the development of the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Core Set for multimorbidity rehabilitation. ICF Core Sets are a selection of essential categories from the full ICF classification that are considered most relevant for describing the functioning of a person with a specific health condition or in a specific healthcare context. This study aims to develop and validate an ICF Core Set for exercise-based multimorbidity rehabilitation. Unlike system- or disease-specific rehabilitation, multimorbidity rehabilitation entails using a modified structure that accommodates all conditions that an individual with multimorbidity has.

Methods: The three-phase, multi-method process created by the WHO and ICF Research Branch will be followed. The process will involve conducting four preparatory studies (phase 1), including (i) a systematic literature review (to examine researcher perspectives), (ii) a qualitative study (to examine patient perspectives), (iii) an expert survey (to examine health professional perspectives), and (iv) an empirical study (to examine clinical perspectives). This will be followed by an international consensus conference (phase 2) where lists of ICF categories resulting from phase 1 studies will be consolidated into a first version of an ICF Core Set for multimorbidity rehabilitation, which will be validated using an international comparative data analysis (phase 3).

Conclusion: An ICF Core Set created for multimorbidity rehabilitation will (1) benefit patients with multimorbidity who are often excluded from clinical trials of single-disease rehabilitation programs, (2) ensure precise and comprehensive assessment and documentation of functioning and disability relevant to this patient population, (3) help rehabilitation providers and their patients and/or caregivers when setting rehabilitation goals and planning rehabilitative interventions to achieve those goals, (4) help researchers in the synthesis of evidence for multimorbidity rehabilitation and facilitate the comparability of data across studies and countries, and (5) provide the scientific basis from which assessment tools can be derived for use in clinical and research settings and health care administration.

Trial registration: COMET database (https://www.comet-initiative.org/Studies/Details/3266).

Keywords: ICF core sets; core outcome sets; functioning; multimorbidity; rehabilitation.

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Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

**Figure 1.**
Interactions between components of the ICF.

**Figure 2.**
Time schedule of the process to develop and validate ICF Core Sets for multimorbidity rehabilitation.

**Figure 3.**
General overview of the ICF linking process (adapted from a template for study protocols regarding ICF Core Set development by the ICF Research Branch).

See this image and copyright information in PMC

References

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1. Bricca A, Harris LK, Jäger M, et al. Benefits and harms of exercise therapy in people with multimorbidity: A systematic review and meta-analysis of randomised controlled trials. Ageing Res Rev 2020, [cited 2024 Sep 16];63. Available from: https://pubmed.ncbi.nlm.nih.gov/32896665/ - PMC - PubMed
1. Valabhji J, Barron E, Pratt A, et al. Prevalence of multiple long-term conditions (multimorbidity) in England: a whole population study of over 60 million people. J R Soc Med 2024; 117(3): 104–117, Available from: https://pubmed.ncbi.nlm.nih.gov/37905525/ - PMC - PubMed
1. Berner K, Tawa N, Louw Q. Multimorbidity patterns and function among adults in low- and middle-income countries: a scoping review protocol. Syst Rev 2022; 11(1), Available from: https://pubmed.ncbi.nlm.nih.gov/35799277/ - PMC - PubMed
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Protocol for the development and validation of a Core Set for exercise-based rehabilitation of adults with multiple long-term conditions (multimorbidity) based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework

Affiliations

Protocol for the development and validation of a Core Set for exercise-based rehabilitation of adults with multiple long-term conditions (multimorbidity) based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF) framework

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

Full Text Sources

Miscellaneous