Journal of the Formosan Medical Association (2013) 112, 691e698

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ORIGINAL ARTICLE

Evolution of system for disability assessment based on the International Classication of Functioning, Disability, and Health: A Taiwanese study
Sue-Wen Teng a, Chia-Feng Yen b, Hua-Fang Liao c, Kwan-Hwa Chang d, Wen-Chou Chi e, Yen-Ho Wang f, Tsan-Hon Liou g,h,*, Taiwan ICF Team
Bureau of Nursing and Health Services Development, Department of Health, Taipei, Taiwan Department of Public Health, Tzu Chi University, Hualien, Taiwan c Chinese Association of Early Intervention of Professional for Children with Developmental Delays, Hualien, Taiwan d Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan e Department of Information Management, National Chung Cheng University, Chiayi, Taiwan f Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan g Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan h Graduate Institute of Injury Prevention, Taipei Medical University, Taipei, Taiwan
b a

Received 26 March 2013; received in revised form 3 September 2013; accepted 3 September 2013

KEYWORDS
disability; International Classication of Functioning; Disability; and Health;

Background/Purpose: The criteria for disability were mainly based on the medical model, and the candidates for disability benets were identied by physicians mainly depending on their degree of bodily impairment, but without sufcient evaluation of their activity, participation, and environment in Taiwan. According to the People with Disabilities Rights Protection Act, the assessment of a persons eligibility for disability benets was required to be based on the International Classication of Functioning, Disability, and Health (ICF) framework since July 11, 2012. This study investigated a proposed system to assess patients eligibility for disability in Taiwan, based on the ICF.

* Corresponding author. Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, 291 Jhongjheng Road, Jhonghe, New Taipei City 235, Taiwan. E-mail address: peter_liou@s.tmu.edu.tw (T.-H. Liou). 0929-6646/$ - see front matter Copyright 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved. http://dx.doi.org/10.1016/j.jfma.2013.09.007

692 World Health Organization

S.-W. Teng et al.

Methods: We have initiated a national decision-making process involving members of Taiwans ICF Team. We facilitated 16 group discussions on the ICF coding system, in which 199 professionals participated. In each group, one member led the group discussion until a consensus was reached. Results: We have developed a process to determine the eligibility of people with disabilities. This study set up the standards, tools, and practice manuals for each category. We have also developed a core set for disability assessment. Conclusion: We implemented a new system to assess patients eligibility for disability. The proposed assessment protocol and tools require further validation. Copyright 2013, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Introduction
Disability may be dened as a negative interaction between the functional impairments and environment of an individual. People with disabilities often experience difculty in daily life and are limited in their activities and social participation. The Ministry of the Interior in Taiwan reported that the number of people with disabilities nationwide in 2003 was 861,030 (3.8% of the total population); this gure had increased to 1,100,436 by 2011 (4.6% of the total population).1 The percentage of disabled people shows a yearly increasing trend (Fig. 1). People with disabilities often require special support in various areas to assist them in adjusting to normal daily life, such as education, housing, work, and social benets.2 Since 1980, the Taiwanese government has applied certain legislative procedures to create and revise categories of disability. A person who fullls the criteria to determine eligibility for disability benets may be granted cash and in-kind services from the government. However, the criteria for disability were mainly based on the medical model, which considered disability as a physical and mental impairment. Thus, candidates for disability benets were identied by physicians mainly depending on their degree of bodily impairment, but without sufcient evaluation of their activity, participation, and environment. In 2007, the Taiwanese Legislative Yuan passed a constitutional amendment known as the People with Disabilities Rights Protection Act.3 Under this act, the assessment of a persons eligibility for benets was required to be based on the International Classication of

Functioning, Disability, and Health (ICF) framework since 2012. The ICF framework was developed by the World Health Organization (WHO) to describe health and disability at the level of both the individual and society. It examines a persons functioning at the level of body, person, and society, and provides denitions for operational assessment.4 The ICF system provides a universal framework for assessing the functional limitations of any person. The ICF classications are based on the understanding that for any person, various factors interact, and all of these factors must be considered in making a proper assessment; hence, several domains of assessment are included, such as body function and structure, activity and participation, and environmental and personal factors (Fig. 2). The ICF system has been universally accepted by the United Nations since 2001. It provides an excellent scientic approach to collect reliable statistics on disabled populations.5,6 In Japan, Italy, and Australia, the ICF framework has been used to guide clinical measurement and evaluation of patients requiring rehabilitation, home care, old-age care, and disability support.7e9 The ICF framework was also used in the Multi-Country Survey Study conducted between 2000 and 2001, and the World Health Survey Program of 2002 and 2003, to measure the health status of general populations in 71 countries.7 To prepare for reform in the system of disability assessment, the Taiwanese government authorized professionals to form a Taiwanese ICF Team. This task force includes physicians, dentists, nurses, physical therapists, occupational therapists, social workers, psychologists,

Figure 1 The trend and estimated prevalence rates for disability in Taiwan between 1997 and 2011. Black bars indicate the number of people with disability each year, and the line shows the percentage of people with disability among the general population each year.

Disability evaluation based on the ICF in Taiwan

Heath condition (disorder or disease)

693 her ideas on appropriate methods for formulating standardized assessment tools. These ideas were communicated either during the meetings or by e-mail. The groups then designed suitable assessment tools and proposed the cutoff values for the degree of disability. The cutoff points were based on the members clinical experience as well as empirical data. (3) Developing assessment tools for activity and participation (d codes)

Body Functions and Structures

Activities

Participation

Environmental Factors

Personal Factors

Figure 2 Framework of International Classication of Functioning, Disability, and Health (ICF) and interactions between the components.

special education teachers, vocational assessment workers, public health scholars, and representatives of welfare groups for people with disabilities. The teams mission was to develop a standardized instrument to assess disability and to formulate Taiwans policies on disability. The current study examines the process of introducing these reforms, and documents the experience gained in the eld of disability assessment in Taiwan between 2007 and 2012.

Methods
The process of reforming disability assessment based on the ICF framework began in 2007. The main steps were as follows: (1) Team building and meeting A national decision-making process was organized. From June 2008 to April 2010, we facilitated 16 focus groups attended by 199 professional experts. Eight groups focused on the chapters of body functions and structures, and eight groups focused on activity or participation and the environment. The group members were researchers and practitioners drawn from various medical specialties, as well as representatives of social welfare associations, all of whom should be familiar with the ICF and disability assessment. Each focus group included 5e20 experts, and meetings were held periodically; one leader was appointed in each group to lead the discussions and help the group reach agreement through a consensus or by voting. Several meetings were also held, at which only the group leaders were present and the following principles were decided on: (1) all codes were at two-level categories; (2) both ICF and ICF-CY codes should be considered; and (3) insufcient evidence was available on reliable cutoff values to determine the degree of disability; thus, for environmental factors, grading would be restricted to a binary variable: barrier (negative) and no barrier. (2) Developing assessment tools for body function (b code) and structure (s code) In the focus groups addressing the chapters on body functions and structures, each member contributed his or

Initially, the teams focused on developing an operation manual for the existing 137 categories of d codes. The manual covered assessment procedures, tools, and the criteria for all codes of activities and participation. However, this task force then became aware that the WHO had developed a second edition of the WHO Disability Assessment Schedule, (WHODAS 2.0), which included an assessment of difculty in daily activities and social participation.10 A review of the literature showed that WHODAS 2.0 was compatible with the ICF component activities and participation.11 Furthermore, WHODAS 2.0 can be used cross-culturally and has been tested in more than 10 countries.12 Our group discussed this issue over several meetings and decided to use the 36-item version of WHODAS 2.0 rather than the ICF component activities and participation (d code).11 The WHODAS scoring system is based on itemeresponse theory, with domain scores comprising the sum of all items in a domain. A persons summary score is the sum of the scores for all 36 items. The standardized score for each domain and the summary score were calculated based on the manual for WHODAS.13 The standardized scores ranged from 0 (least difculty) to 100 points (greatest difculty). After examining numerous population norms, our experts agreed that the domain and summary scores for WHODAS 2.0 provided a useful solution for grading the level of disability. The WHODAS 2.0 has six domains. Domain 1 refers to cognition, understanding, and communication, and includes six items. Domain 2 comprises ve items relating to mobility. Domain 3 refers to self-care and includes four items. Domain 4 comprises ve items on the ability to get along well with other people. Domain 5-1 covers household activities and includes four items, and Domain 52 covers work and school activities and includes four items. Domain 6 examines participation and includes eight items. Based on WHO guidelines and considering cultural difference, with permission we translated and modied WHODAS 2.0 into the Chinese version of Functioning Scale of Disability Evaluation System (FUNDES). (4) Developing assessment tools for environment (e code) Environmental factors were selected according to expert consensus. After several rounds of discussion, the focus groups summarized a list of ICF categories for environmental factors, as follows: e110, products or substances for personal consumption; e115, products and technology for personal use in daily living; e120, products and technology for personal indoor and outdoor mobility and transportation; e125, products and technology for communication; e130,

694 products and technology for education; e165, assets; e225, climate; and e570, social security services, systems, and policies. As mentioned above, environmental factors were rated either as a barrier (negative score) or as no barrier, without further grading.

S.-W. Teng et al.

Process of Disability Assessment

Past

Present

Results
The task team drafted a new assessment system, including criteria and practice manuals for the b, s, d, and e codes of the ICF. Between September 2008 and April 2010, those groups held 57 meetings to discuss ICF disability assessment (22 meetings for b and s codes, and 35 meetings for d and e codes); 19 meetings for group leaders; and 75 meetings focusing on the child and youth version (ICF-CY). The meetings were held nationwide. (1) Disability assessment tools During the meetings and discussion, the experts involved in this study decided that only two-level categories should be accepted for clinical disability assessments.14 Professionals in each focus group also agreed that a new system for functional assessment should be based on existing tools, such as the Wechsler Adult Intelligence Scale (third edition) for intelligence assessment, and the Berg Balance Scale for balance evaluation. The Taiwanese ICF team members thus developed operational manuals and training courses for assessors that incorporated currently used instruments.15 (2) Procedures for determining eligibility for disability benets The procedure changes implemented to the disability evaluation system are shown in Fig. 3. The proposed system of assessing disability included two stages, both of which were to be conducted by the appraising hospital. The rst step is performed by physicians and focuses on the patients body function and structure (b and s codes). The second step must be performed by another professional, and focuses on the patients activity and participation as well as environmental factors (d and e codes). After assessment at the hospital, the patients is transferred to a needs assessment system so that his or her need for state support and services can be thoroughly evaluated. The process of disability assessment thus requires at least two authorized specialists per patient. One or more physicians evaluate the applicants impairments at the level of body functions and structures according to the items related to ICF categories. The second tester evaluates the applicants limitations on activity and participation using the WHODAS 2.0 items and the environmental factors. Qualied practitioners who have worked for at least a year in their relevant eld (i.e., physical therapy, occupational therapy, speech therapy, psychology, or social work) may become authorized as appraisers following a year of related working experience. Between 2010 and 2012, we used the WHODAS 2.0 appraisers Training Manual and Interview Guide to train more than 6000 people to conduct disability evaluations in Taiwan.

Hospital Performed by Physician

Hospital Step 1: Performed by Physician: body function and structure (b and s categories of ICF) Step 2: Performed by non-physician professionals: activity, participation and environment (d and e categories of ICF)

Disability Certificate: Degree of disability is determined according to 16 categories and 4 levels

Certificate of Disability Assessment Outcome (disability type and level)

Needs Assessment Multidisciplinary professionals of Ministry of Interior

Disability confirmed by Government Issue identification card and arrange appropriate welfare support

Figure 3 Changes to the procedure of disability evaluation system in Taiwan, past and present.

(3) Development of a core set for disability determination The task force used the Delphi technique to develop a core set for disability assessment. For body function and structure components, there were 43 categories included in the core set of disability. Most items were second-level, including those of the ICF-CY, however, to provide greater detail, some items had forth level. For the assessment of activity and participation, this task force designed two scales to measure a patients functional status. These were the Functioning Scale of Disability Evaluation System Adult Version (FUNDES-Adult) for people aged 18 years and older, and the FUNDES-Child version for children and youths (age 6e17.9 years).16,17 The two FUNDES scales were separately designed and were based on the WHODAS 2.0 and the Child and Family Follow-up Survey (CFFS) (Fig. 4). The FUNDES-Adult includes 97 items, with performance and capability dimensions in Domains 1e6 (cognition, mobility, self-care, getting along, life activities, and participation) and capability and capacity dimensions in Domain 8 (motor action). Domain 7 (environmental attributes) includes items to measure the perceived environmental barriers the patient may encounter. The FUNDES-Child version has 74 items that cover four aspects: physical and emotional health; participation; the child and adolescent factors inventory; and the child and adolescent scale of environment. The participation section

Disability evaluation based on the ICF in Taiwan

Disabling condition
Disease, illness, or other health problems Injuries Mental or emotional problems

695

Body Functions and Structures

b110 b144 b167 b235 s330 b440 s560 b735 b810 b117 b122 b139 b140 b164 b230 s320 b430 s540 b730 s760 b147 b152 b160 b16701 b16711 b210 b310 b320 b330 s340 b410 b415 s430 b610 b765 b830 b510 b620 s730 s810 s530 b710 s750

Activities
FUNDES-adult ( 18 years old)

Participation

Domain 1 : Cognition Domain 2 : Mobility Domain 3 : Self-care Domain 4 : Getting along Domain 5 : Life activities Domain 6 : Participation FUNDES-child ( Domain 1 Domain 2 Domain 3 18 years old)

Home participation Neighborhood and community participation School participation

Environmental Factors
e110 e125 e225 e115 e130 e570 e120 e165

Personal Factors
Age, sex, pre-morbid disability, duration of disability, education level etc.

Figure 4 Core set for disability assessment based on ICF. FUNDES Z functioning scale of disability evaluation system. Note. From WHO Disability Assessment Schedule 2.0, by World Health Organization, 2011, http://www.who.int/classications/icf/whodasii/ en/index.html, Copyright 2011, WHO, Adapted with permission.

includes items to measure independence and frequency. The second section of the FUNDES-Child version addresses participation, and was developed from the child and adolescent scale of participation (CASP).18e20 Other sections measure health conditions or body functions, and one section presents the environmental factors of the ICF-CY. The participation section has four domains: home participation (6 items), neighborhood and community participation (4 items), school participation (5 items), and home and community living activities (5 items). Items in the participation section are classied into independence and frequency dimensions. The psychometric properties of the CASP-Traditional Chinese version have been validated.16 (4) Determination of the level of disability In Taiwan, prior to 2012 the eligibility criteria for disability support were based on the medical model. An authorized physician evaluated and reported the applicants impairments or problems in body functions and structures using the ofcial Disability Eligibility Determination Scale (1980 edition). However, in 2007 the system of evaluation was reformed, and the process of disability assessment changed accordingly. In addition to evaluating the applicants impairments in body functions and structures, assessment of his or her activity and participation in daily life must now be included. The nal determination of the patients degree of disability and eligibility for state support depends on the combined results for the b and s codes and the summary score of FUNDES. This proposed

new evaluation system has been implemented without an extensive database or evidence, and further studies are required to validate it. Such studies should include the assessment results for people with disabilities rather than simply expert consensus as in the current study. (5) A testing trial Prior to implementation, a trial was conducted. We collected data and compared them with those obtained from the previous system. There were 7098 adults (3869 men and 3229 women) participating in this study. The average age was 57.37 17.58 years and 60.11 18.66 years, respectively. The causes of disability included visual impairment, hearing impairment, speech dysfunction, motor dysfunction, mental intellectual impairments, vital organ impairment, facial damage, dementia, autism, chronic mental disease, and rare disease. The three leading causes of disability were motor dysfunction (28.5%), chronic mental disease (26.2%), and hearing impairment (10.0%). The results showed a 49.7% agreement between the two evaluation systems.

Discussion
In Taiwan, the system for evaluating a patients disability and eligibility for state support has been undergoing a process of reform since 2007. This study focused on the development of a suitable method of assessment. The

696 rights of people with disabilities are protected by this reform, and the new system is based on the biopsychosocial model. Thus, holistic and multidisciplinary approaches are required for disability assessment. The implementation of this new system has several implications for Taiwan. The implications for medical providers, government bodies, and Taiwanese citizens are briey discussed here. For hospitals and other medical providers, the number of personnel able to assess disability must be expanded, and multidisciplinary professionals will be required to complete the evaluations. The costs to the hospital for the increased time and space given to disability assessments will rise. For local government, the budget for disability assessments has increased markedly from July 2012. Furthermore, local governments must develop a method to resolve cases for who the result of needs assessment is disputed. The third main implication concerns central government, which must cultivate the development of professionals to assess disability according to the ICF framework, and authenticate their qualication. Central government must also provide diverse resources and an effective delivery system to cater for various needs, and must integrate the assessment process with other social welfare services such as long-term care or medical care. The fourth implication of reforming the assessment system concerns people with disabilities and their families. Certain patients might be affected by a change in their classication of disability level and might no longer be eligible for services from the social welfare system. Furthermore, the time required for the processing of a evaluation and needs assessment might be prolonged. These implications pose challenges for our country and must be addressed. Although the ICF framework has been implemented in many countries, thus far little experience has been documented on using the ICF system to classify people with disabilities on a nationwide basis.8,21e24 The biopsychosocial model reconceptualizes disability as arising from the interaction between a persons functional status with the physical, cultural, and policy environments.25,26 If the environment is designed to accommodate the full range of possible types of human functioning, and incorporates appropriate accommodation and support, people with functional limitations would not be disabled and would be able to participate fully in society.27,28 Interventions are thus not limited to the individual level (e.g., medical rehabilitation) but are also conceptualized at the societal level. For example, the introduction of barrier-free designs to make the environment more accessible for people with mobility impediments, inclusive education systems, and community awareness programs to combat the stigma of disability will all enable people with disabilities to lead fuller lives. The ICF is based on a theoretical model that draws on a social understanding of disability, and thus, avoids a dualistic all or none denition.29 People are identied as disabled based not only on a medical condition but also on a detailed review of their functioning within various domains. Thus, the Taiwanese government has selected the ICF as the preferred integrative model to assist with the reform of disability assessment.30 The estimated prevalence of disability differs worldwide. The reported prevalence ranges from less than 1% in

S.-W. Teng et al. Kenya and 5% in South Africa and Bangladesh to 20% in New Zealand.31,32 In Taiwan, the disability prevalence was 4.6% in 2011.1 Difference in the estimated prevalence among countries may arise through several factors, including different cutoff points for eligibility for disability benets, different methodologies and data collection, and variation in the quality of study design. An important factor inuencing the reported prevalence rate is the purpose of disability assessment; in Taiwan, this purpose is inuenced by politics.33 These consist of 32 bodily functions, 16 body structures, and participation in 48 activities from the ICF checklist.14 In Europe, only ve bodily functions and 15 activity participation codes are used to evaluate a patients eligibility for social security.34 In this Taiwanese study, 140 codes/items for adults and 117 codes/items for children were selected to evaluate disability. Among them, 43 codes were drawn from the b and s categories of ICF, and others were from the WHODAS 2.0 and CFFS respectively. Demonstrating the application of this core set remains an important challenge for the Taiwanese government to address. Another important issue in the reform of disability assessment was establishing cutoff points for the degree of disability. Insufcient evidence has been accumulated worldwide to clearly dene the criteria. The cutoff points are inuenced largely by the budget for social welfare in a specic country. Taiwans social welfare system is a residual model of social welfare and allocates more extensive services to people with severe disabilities than to those with mild ones; this principle includes care in kind, personal care budgets, and cash benets. As a result, determining a patients nal disability rating using various qualier codes remains a challenge. Studies conducted by the WHO, and a separate Italian study, have suggested that a large sample is necessary to determine appropriate weight indices and disability scores.10,35 This remains another important task facing the Taiwanese government.

Recommendations for further studies

The nal determination of a persons degree of disability is obtained from a summary of the ICF codes, including qualiers. However, no empirical evidence or nationwide data currently exist to justify the use of certain cut-off values for disability. The accuracy of ICF qualiers in determining the level of disability assessment has yet to be established. Experts in our study adopted or modied current measures to create new protocols and tools. These instruments and methods require long-term testing and validation. Welfare services and social support should be carried out for people with disability according to their results of disability assessment and needs assessment. The ICF provide a linking between the medical assessment, functional evaluation, and needs assessment for people with disability. This study mainly focused on disability assessments. Further studies on needs assessments are required. The implementation of the ICF system in Taiwan will facilitate international studies comparing the results of diverse interventions, service performance, patient satisfaction, and cost effectiveness.

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14. World Health Organization. ICF- Checklist. http://www3.who. int/icf/checklist/icf-checklist.pdf; 2007 [accessed 05.06.12]. 15. Department of Health. Regulations for the identication of people with disabilities. http://dpws.sfaa.gov.tw/commonch/ home.jsp?menudataZDisbMenu&contlinkZap/idfbook_view. jsp&datasernoZ200810290002&msernoZ200805260011&sernoZ 200805260018; 2012 [accessed 05.06.12]. 16. Hwang AW, Liou TH, Bedell GM, Kang LJ, Chen WC, Yen CF, et al. Psychometric properties of the Child and Adolescent Scale of Participation - Traditional Chinese version. Int J Rehabil Res 2013;36:211e20. 17. Liao HF, Yen CF, Hwang AW, Liou TH, Chang BS, Wu TF, et al. Introduction to the application of the functioning scale of the Disability Evaluation System. Formosan J Med 2013;17: 317e31. 18. Bedell GM. Developing a follow-up survey focused on participation of children and youth with acquired brain injuries after discharge from inpatient rehabilitation. NeuroRehabilitation 2004;19:191e205. 19. Bedell G. Further validation of the Child and Adolescent Scale of Participation (CASP). Dev Neurorehabil 2009;12:342e51. 20. Bedell GM, Khetani MA, Cousins MA, Coster WJ, Law MC. Parent perspectives to inform development of measures of childrens participation and environment. Arch Phys Med Rehabil 2011; 92:765e73. 21. Stucki G, Cieza A, Ewert T, Kostanjsek N, Chatterji S, Ustu n TB. Application of the International Classication of Functioning, Disability and Health (ICF) in clinical practice. Disabil Rehabil 2002;24:281e2. 22. Stucki G, Reinhardt JD, Cieza A, Brach M, Celio M, Joggi D, et al. Developing Swiss paraplegic research: building a research institution from the comprehensive perspective. Disabil Rehabil 2008;30:1063e78. 23. Stucki G, Ewert T. How to assess the impact of arthritis on the individual patient: the WHO ICF. Ann Rheum Dis 2005;64:664e8. 24. Sanches-Ferreira M, Simeonsson RJ, Silveira-Maia M, Alves S, Tavares A, Pinheiro S. Portugals special education law: implementing the International Classication of Functioning, Disability and Health in policy and practice. Disabil Rehabil 2013;35:868e73. 25. Shakespeare T, Watson N. Defending the Social Model. Disabil Soc 1997;12:293e300. 26. Hughes B, Paterson K. The social model of disability and the disappearing body: towards a sociology of impairment. Disabil Soc 1997;12:325e40. 27. Huang J, Pan XL, Li A. Multi-level modelling of the factors that inuence the participation of disabled rural individuals in social medical insurance in China. BMC Health Serv Res 2013;13:58. 28. Day AM, Theurer JA, Dykstra AD, Doyle PC. Nature and the natural environment as health facilitators: the need to reconceptualize the ICF environmental factors. Disabil Rehabil 2012;34:2281e90. stu 29. Kostanjsek N, Good A, Madden RH, U n TB, Chatterji S, Mathers CD, et al. Counting disability: global and national estimation. Disabil Rehabil 2013;35:1065e9. 30. Stucki G, Cieza A, Melvin J. The International Classication of Functioning, Disability and Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy. J Rehabil Med 2007;39:279e85. 31. Suliman S, Stein DJ, Myer L, Williams DR, Seedat S. Disability and treatment of psychiatric and physical disorders in South Africa. J Nerv Ment Dis 2010;198:8e15. 32. Shaw C, Blakely T, Tobias M. Mortality among the working age population receiving incapacity benets in New Zealand, 1981e2004. Soc Sci Med 2011;73:568e75. 33. Oliver M. Theories in health care and research: theories of disability in health practice and research. BMJ 1998;317:1446e9.

Acknowledgments
This study was supported by the Department of Health, Executive Yuan, Taiwan (Nos. 98M8178, 99M4080, 99M4073, 100M4145, and 101M4100). We would like to thank all the experts who were the leaders of the eight subgroups based on the chapters of body function and structure of ICF. Their contribution was to coordinate the members opinions and develop the assessment tools. The Taiwanese ICF Team leaders include the following people: Yen-Nan Chiu, TienChen Liu, Lu Lu, Shyh-Dye Lee, Fu-Sung Lo, Tai-Lung Cha, Ben-Sheng Chang, Shu-Jen Lu, Ting-Fang Wu, Ti-Li Kao, and Kuo-Lung Lee.

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