ObjectiveThis study aimed to develop Clinical Functioning Information Tool-musculoskeletal, an International Classification of Functioning, Disability and Health-based clinical tool for the assessment and reporting of the functioning and rehabilitation potential of patients with a musculoskeletal condition.DesignThis multistep, mixed-methods tool development process encompassed developing an initial shortlist of International Classification of Functioning, Disability and Health categories (comprising the aggregation of the International Classification of Functioning, Disability and Health Core Sets for musculoskeletal conditions and a literature search), identifying the Clinical Functioning Information Tool-musculoskeletal items feasible for clinical use via a two-round Delphi survey, developing a simple description for each item and deciding on the rating scale through development working group consultations. These consultations were also instrumental at each step of tool development.ResultsBased on a shortlist of 33 categories, the Delphi survey generated 17 items (7 body function and 10 activity and participation categories), which can be rated with a 0-4 scale (0 = no problem to 4 = complete problem) accompanied with rating specifications or with a 0-10 numeric rating scale without specification.ConclusionsClinical Functioning Information Tool-musculoskeletal can be used by rehabilitation professionals to support individualized care and track functional outcomes. It can also be employed in research and public health. Psychometric testing and cross-cultural validation will be pursued to ensure Clinical Functioning Information Tool-musculoskeletal's scientific robustness and applicability across diverse settings.

Rehabilitation physicians worldwide have been called to take action to explore and implement the International Society of Physical and Rehabilitation Medicine's Clinical Functioning Information Tool - ClinFIT. ClinFIT is an International Classification of Functioning, Disability and Health-based and clinician-administered tool that can be used to systematically assess and report functioning of different patient populations across the care continuum and support the monitoring of rehabilitation outcomes. One essential action step is getting familiar with ClinFIT. It is possible to create a ClinFIT version for your setting and purpose, either by tailoring an existing ClinFIT version or by developing a new version for a specific health condition or context. This paper describes how to create a ClinFIT that works for you. Specifically, it provides you with information about current ClinFIT versions and what to consider when creating the desired ClinFIT version and presents a step-by-step guide for either tailoring an existing ClinFIT version or for developing a new ClinFIT version. This paper also introduces reporting considerations to enhance clinical utility as well as emerging opportunities offered by artificial intelligence and other digital technologies. Lastly, the authors invite all PRM physicians worldwide to join the ClinFIT community as knowledge-brokers and as champions, actively disseminating information about ClinFIT and participating in ClinFIT research.

In October 2024, an Expert Meeting hosted by the United States National Academies of Sciences, Engineering, and Medicine (NASEM) took place in Washington, D.C. (USA). The participating experts discussed ideas for advancing the integration of functioning in rehabilitation practice and research by focusing on International Classification of Functioning, Disability and Health (ICF)-based data collection tools with particular emphasis on the International Society of Physical and Rehabilitation Medicine's universal clinical functioning information tool (ClinFIT). This paper shares key insights revealed in these discussions: Implementing practical, patient-centric data collection tools strengthens rehabilitation; scientifically robust research is essential to provide evidence on the utility of ICF-based tools in clinical practice and the implementation of ClinFIT in clinical routine; and concrete solutions are needed to enable clinicians to adopt new assessment tools in practice are needed. To support this endeavour, this paper calls on physical and rehabilitation medicine (PRM) physicians worldwide to explore ClinFIT and integrate it in clinical practice and research.

Objective: to report on the development and global testing of the COVID-19 version of the International Classification of Functioning, Disability and Health-based Clinical Functioning Information Tool called “ClinFIT COVID-19” to collect functioning data of rehabilitation patients across the care continuum to establish an interval-scaled functioning score. Design: Multicentre, cross-sectional observational study. Subjects/Patients: Rehabilitation patients in acute, post-acute, and long-term settings. Methods: Three context-specific versions (13–16 ICF categories) of ClinFIT-COVID-19 were administered to collect information on patient functioning. Rasch analysis examined psychometric properties and generated conversion tables from ordinal raw scores to a 0–100 interval metric. Results: Twenty-six study centres in 17 countries across the globe collected data from 1,747 patients. Problems in exercise tolerance functions were most frequently reported in the acute and post-acute settings (74.2%; 87.6%), while long-term care patients most frequently reported pain as problematic (71.1%). With a testlets approach and item splitting, all 3 ClinFIT COVID-19 versions satisfied Rasch model expectations (item-trait χ² p > 0.05; PSI 0.742–0.812), making it feasible to develop respective transformation tables. Conclusion: This study found the psychometric properties of ClinFIT COVID-19 acceptable. Future studies are needed to validate the use of the transformation tables to monitor functioning and evaluate intervention impact.

INTRODUCTION:Functioning is the third health indicator besides mortality and morbidity. Although Korea periodically collects functioning information, the functioning indicator has not been generated yet. This study aimed to evaluate how functioning information is currently collected in Korea's health and disability surveys, especially in terms of comparability and comprehensiveness, using the International Classification of Functioning, Disability and Health (ICF) as a reference framework. METHODS:Data sources included three health and disability surveys in Korea, namely the Population and Housing Census, the Korean National Health and Nutrition Examination Survey, and the Survey on the Living condition of Persons with Disabilities, and two international ICF-based surveys, the International Spinal Cord Injury Survey and the Model Disability Survey. Functioning information was linked by category to the ICF Generic-30 Set utilizing the ICF linking rules. RESULTS:Three ICF categories - d450 walking; d510 washing oneself; d540 dressing ̶ were covered by all the data sources. Excluding the Population and Housing Census, which inherently differs from the other data sources, all the surveys addressed six ICF categories - b152 emotional functions; b280 sensation of pain; d240 handling stress and other psychological demands; d450 walking; d510 washing oneself; d540 dressing. The ICF categories b152 emotional functions and b130 energy and drive functions were the most frequently covered across all the surveys. Despite of the common ICF categories, important differences in the operationalization of questions and response options were found. CONCLUSIONS:The overlap of content of health and disability surveys in Korea enables interoperability with other data sources. Available functioning data can be used for estimating the functioning indicator and metric, as recommended by WHO, which can serve as a valuable epidemiological indicator for complementing mortality and morbidity indicators and for estimating and monitoring rehabilitation or long-term care needs of the Korean population.

OBJECTIVE:This study aimed to develop Clinical Functioning Information Tool-musculoskeletal, an International Classification of Functioning, Disability and Health-based clinical tool for the assessment and reporting of the functioning and rehabilitation potential of patients with a musculoskeletal condition. DESIGN:This multistep, mixed-methods tool development process encompassed developing an initial shortlist of International Classification of Functioning, Disability and Health categories (comprising the aggregation of the International Classification of Functioning, Disability and Health Core Sets for musculoskeletal conditions and a literature search), identifying the Clinical Functioning Information Tool-musculoskeletal items feasible for clinical use via a two-round Delphi survey, developing a simple description for each item and deciding on the rating scale through development working group consultations. These consultations were also instrumental at each step of tool development. RESULTS:Based on a shortlist of 33 categories, the Delphi survey generated 17 items (7 body function and 10 activity and participation categories), which can be rated with a 0-4 scale (0 = no problem to 4 = complete problem) accompanied with rating specifications or with a 0-10 numeric rating scale without specification. CONCLUSIONS:Clinical Functioning Information Tool-musculoskeletal can be used by rehabilitation professionals to support individualized care and track functional outcomes. It can also be employed in research and public health. Psychometric testing and cross-cultural validation will be pursued to ensure Clinical Functioning Information Tool-musculoskeletal's scientific robustness and applicability across diverse settings.

Objective: To develop data-driven functional staging cutoff scores for the Clinical Functioning Information Tool (ClinFIT) total raw score to stratify patients according to rehabilitation provision and intensity. Methods: This observational study included adult inpatients (n = 270) admitted to a tertiary rehabilitation unit. ClinFIT total scores at admission were analysed alongside the Therapy Disciplines domain of the Rehabilitation Complexity Scale to represent rehabilitation intensity. Receiver Operating Characteristic analysis was used to identify optimal cutoff points distinguishing between levels of rehabilitation intensity. Subgroup analyses were conducted by age, sex, and diagnosis. Results: Participants were predominantly male (54.1%), with a mean age of 62.9 ± 14.3 years. ClinFIT total raw scores improved significantly across all health conditions at discharge compared with admission (p < 0.001), reflecting substantial functional recovery during inpatient rehabilitation. Two ClinFIT total score cutoffs were identified: 135 (light vs moderate) and 192 (moderate vs high intensity), with acceptable discriminatory performance (AUCs: 0.720, 0.748, respectively). Subgroup analyses supported the robustness of this 3-level staging system across demographic and diagnostic groups. Conclusion: This study provides evidence-based cutoff scores for ClinFIT, supporting its clinical use for stratifying rehabilitation provision and intensity. These findings may enhance clinical decision-making, optimize resource allocation, and promote wider adoption of the ClinFIT. Further validation in external and diverse populations is warranted.

In line with the World Health Organization's Rehabilitation 2030 initiative that led to its landmark resolution on rehabilitation, the Physical and Rehabilitation Medicine (PRM) Section and Board of the European Union of Medical Specialists have been developing functioning-based standards and tools using the International Classification of Functioning, Disability and Health (ICF) as a reference framework the past few years. This evidence brief aims to enable rehabilitation practitioners to implement these functioning-based standards and tools in rehabilitation care, management, and programming by clarifying functioning as the foundational concept for rehabilitation, introducing the functioning-based standards and tools and presenting concrete applications. This evidence brief also calls for the continuous development of these standards and tools and discusses the implementation challenges and opportunities in the context of the interaction between practice, science and governance.

Objective: To examine the functioning profile of people with neurological disorders who access rehabilitation services through ClinFIT Generic-30. Methods: The functioning profile of people with neurological disorders accessing rehabilitation services was examined using the ClinFIT Generic-30, and the results compared with existing core set (neurological health conditions acute and post-acute,stroke, Multiple Sclerosis, Traumatic Brain Injury,Spinal Cord Injury). Results: Data for 364 people were analysed. The 10 most commonly impaired ICF categories included 3 for Body Functions (exercise tolerance functions (b455), mobility of joint functions (b710), and muscle power functions (b730)) and 7 for Activities and Participation (carrying out daily routine (d230), handling stress and other psychological demands (d240), changing basic body position (d410), maintaining a body position (d415), transferring oneself (d420), walking (d450), and moving around (d455)), while the ICF categories that were severely impaired (ICF qualifiers 3 and 4) in more than 30% of the study cohort were: muscle power functions (b730), carrying out daily routine (d230), walking (d450), moving around (d455), doing housework (d640), and assisting others (d660). Discussion: The current study data suggests that ClinFIT Generic-30 appears to effectively identify impairments and/or restrictions, as perceived by individuals affected by selected health conditions. Conclusion: ClinFIT Generic-30 is a tool that can be used to characterize functioning profile in people with different neurological disorders and to collect important information not addressed by the disease-specific core sets (neurological health conditions acute and post-acute,stroke, Multiple Sclerosis, Traumatic Brain Injury,Spinal Cord Injury).

ObjectivesTo identify official sources that routinely collect data on functioning in Switzerland, to provide an overview of the existing data and its comparability, and to assess the extent to which the data is suitable for developing a functioning metric and indicator.MethodsData sources were identified through an iterative search. Standardized rules were applied to map the functioning information assessed by the sources using a current WHO functioning and disability survey as a reference framework for the content comparison.ResultsFour sources were identified: the Swiss Survey of Health, Ageing and Retirement in Europe (SHARE), the Swiss Health Survey (SHS), the Lausanne cohort 65+ (Lc65+), and the Swiss Household Panel (SHP). All tools addressed sleep functions, energy level, emotional functions, and sensation of pain. Additionally, nine functioning categories were common across three sources.ConclusionPopulation data sources in Switzerland routinely collect comparable functioning data, which can serve as the basis for creating a functioning indicator. Among others, this indicator is relevant to complement mortality and morbidity data and to support both the estimation of rehabilitation and long-term care needs.

Background: The ICF-based Clinical Functioning Information Tool (ClinFIT) was developed as a standardized tool to facilitate the assessment of functioning in clinical and, research settings. Objective: This review describes the contents of commonly used multidimensional outcome measures that describe functioning in rehabilitation settings and maps these measures to ICF categories covered by the ClinFIT to identify commonalities and discrepancies in the content. Methods: A scoping review included a systematic search of PubMed, Embase, Cochrane Library, and other resources. Twelve outcome measures were selected, and their meaningful concepts were linked to the ClinFIT by 2 authors using established ICF linking rules. Content density, bandwidth, and content diversity indices were calculated for each measure. Results: A total of 369 meaningful concepts from the 292 items from 12 measures were selected. Of these, 293 (79.4%) concepts were linked to the ClinFIT categories, with a majority (80.5%) linked to “activities and participation”; however, 76 (20.6%) meaningful concepts could not be linked to any ClinFIT categories. The extent of content coverage varied significantly between measures, reflecting the differences in the scope of each measure. The “activity and participation” categories had the highest bandwidth for all measures (range: 28.6%–71.4%), while the “body function” category was less represented (range: 0%–33.3%). Conclusions: ClinFIT can be the useful outcome measure for functional assessment in rehabilitation settings, as it covers wider concepts, considered important in rehabilitation settings, compared with other common functional outcome measures. It can establish comparability of a minimal data set on functional outcomes across various medical conditions and settings.

Background Achieving sustainable long-term employment is the goal of work integration for persons with acquired brain injury (ABI) or spinal cord injury (SCI). However, decreasing employment rates over time for persons with ABI and SCI indicate that remaining employed in the long-term is a challenge. Purpose To identify the most important risk factors that pose a barrier to sustainable employment of persons with ABI or SCI from a multi-stakeholder perspective, and to propose corresponding interventions that address them. Methods Multi-stakeholder consensus conference and follow-up survey. Results From 31 risk factors to sustainable employment of persons with ABI or SCI identified in previous studies, nine were defined as most important to address with interventions. These risk factors either impacted the person, the work environment or service provision. Potential interventions to address these factors were proposed in mixed condition groups, of which ten were voted on as priority interventions. The follow-up survey revealed strong agreement on the intervention proposals, strong to moderate agreement on impact, but moderate to low feasibility, as most of the interventions were measures at the meso- (service) and macro- (legislation and state regulation) level. Conclusions Holding micro-level stakeholder conferences is a valuable method for identifying the most important risk factors to sustainable employment and for developing measures to address them. To implement measures that involve decisions at the meso- or macro-level, representatives from these levels of the healthcare and social system have to be involved.

BACKGROUND:Functioning is considered a third indicator of health and a key outcome in rehabilitation. A universal practical tool for collecting functioning information is essential. This tool would be ideally based on the International Classification of Functioning, Disability and Health.AIM:To report the results of the development of country/language-specific versions of an ICF-based clinical tool in six European countries.DESIGN:Consensus process.SETTING:Expert conferences.POPULATION:Multi-professional group of rehabilitation professionals in six European countries.METHODS:1) Developed an initial proposal by translating the published English-language version of the simple descriptions into the targeted language; 2) conducted a multi-stage consensus conference to finalize the descriptions; 3) employed a three-stage multi-professional expert panel translation back to English. The consensus conference model was modified for geographically large countries.RESULTS:Croatian, Flemish/Dutch, Greek, Polish, and Turkish versions were produced.CONCLUSIONS:The creation of the country/language-specific simple descriptions is a significant part of the "system-wide implementation of the ICF" initiative that will pave the way for the implementation of the ICF in national health systems.CLINICAL REHABILITATION IMPACT:The practical ICF-based clinical tool with country/language specific versions for standardized reporting of functioning will serve as a means of integrating functioning information in national health systems and additionally for monitoring the effects of rehabilitation interventions.

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OBJECTIVES:Self-assessment instruments are commonly used in audiological rehabilitation. However, several studies highlight the lack of multidimensionality in existing outcome measures, with the consequence that they only partially capture aspects of functioning in everyday life for people living with hearing loss. This study aimed to develop and investigate the content validity of a self-assessment instrument based on the validated Brief International Classification of Functioning, Disability, and Health Core Set for Hearing Loss. DESIGN:The design was a two-part instrument development study. The first part focused on the item-generation process of the instrument, named the Hearing and Functioning in Everyday Life Questionnaire (HFEQ) during an experts' workshop. The second part focused on international content validation of the instrument using group interviews. Strategic sampling was used and 30 adults with hearing loss from India, South Africa, and the United States participated in the group interviews. RESULTS:The expert's workshop resulted in the first version of the HFEQ containing 30 items. The results from group interviews show that the content of the HFEQ was considered to be valid concerning its relevance, comprehensiveness, and comprehensibility. A majority (73%) of the HFEQ items were perceived by the participants as relevant and easy to comprehend. For the remaining 27% of the items, the content was perceived to be relevant in all countries, but some terms and expressions were reported to require rewording or clearer examples. These modifications will be made in the next step of the development process. CONCLUSION:Content validation of the HFEQ demonstrates promising results, with participants perceiving the content as relevant and comprehensible. Further psychometric validation is required to investigate other psychometric properties, such as construct validity and reliability. The HFEQ has the potential to become a valuable new instrument for assessing everyday functioning in people with hearing loss in audiological rehabilitation and in research.

To facilitate the interaction between the health professional and the patient, a framework to guide the rehabilitation process is needed. This framework would encompass three interwoven aspects: the rehabilitation management plan, Individual Rehabilitation Project (IRP), and rehabilitation cycle(s). All three framework aspects focus on the patient and on the aim of rehabilitation, i.e. to optimize a person's functioning across the continuum of care. An IRP is a multi-element, person-centered rehabilitation management scheme, in which rehabilitation is generally provided by a multiprofessional team under the leadership of a physical and rehabilitation medicine (PRM) physician, working in an interdisciplinary manner and together with the patient (or proxy). A reference system for operationalizing functioning and standardizing the process is the International Classification of Functioning, Disability and Health (ICF) - for assessing functioning needs, defining rehabilitation goals and outcomes. The objective of this paper is to present the IRP as a framework for rehabilitation in Europe (EUR-IRP). The specific aims are: 1) to introduce the IRP; and 2) to describe the framework components, elements and variables of the IRP. Demonstration projects (case studies) using the EUR-IRP will be conducted. The present paper presents the efforts to date for developing the EUR-IRP, a key part of the action plan of the PRM Section and Board of the European Union of Medical Specialists to implement the ICF systemwide across the care continuum. This paper serves as another step to bring together practice, science and governance in calling for contribution from rehabilitation clinicians and researchers and professional societies in PRM and beyond.

Objectives To characterize the services of a rehabilitation centre specialized in spinal cord injury/disorder (SCI/D) using the International Classification of Service Organization in Rehabilitation (ICSO-R) 2.0, and to evaluate its potential use in meeting health reporting and certification requirements. Methods The post-acute and outpatient rehabilitation services at this specialized SCI/D centre were described, the SCI/D Framework of rehabilitation service type definitions considered, various rehabilitation centre stakeholders were consulted, and data were collected using the centre’s digital quality management system and institutional management tool. A structured internet search identified the national health reporting and certification systems relevant for SCI/D rehabilitation. The resulting systems were subsequently mapped with ICSO-R 2.0 categories. Results ICSO-R 2.0 categories pertaining to the provider dimension were generally the same across the post-acute and outpatient services. ICSO-R 2.0 highlighted the nuances in service delivery between these 2 service types. Most of the categories could be mapped to at least 1 of the 10 health reporting and certification systems detected in the website search. Conclusion ICSO-R 2.0 can be used to comprehensively describe the rehabilitation services of a specialized SCI/D centre in Switzerland. Despite some challenges, ISCO-R 2.0 has the potential to facilitate national health reporting and certification. LAY ABSTRACT The International Classification of Service Organization in Rehabilitation (ICSO-R) 2.0 has been developed to characterize rehabilitation services in different fields of rehabilitation. The aim of this study was to characterize different rehabilitation services in a centre specialized in spinal cord injury and disorder. Out of 9 rehabilitation services detected, post-acute and outpatient services were described. ICSO-R 2.0 highlighted the nuances in service delivery between these 2 service types. Most of the categories could be mapped to at least 1 of the 10 health reporting and certification systems detected in the website search. Despite some challenges, ISCO-R 2.0 has the potential to facilitate national health reporting and certification.

Since its foundation, Cochrane Rehabilitation has faced challenges with rehabilitation definitions because existing definitions did not indicate what rehabilitation includes and what it excludes. We aimed to develop a comprehensive and shared rehabilitation definition for research purposes to: 1) support the conduct of primary studies and systematic reviews, and 2) identify relevant systematic reviews for knowledge translation purposes. We performed a multimodal study including seven preliminary research and discussion papers, four Consensus Meetings and three Delphi rounds with 80 rehabilitation stakeholders. The Delphi Study aimed to obtain agreement, refine and complete the items composing the definition and meanings of rehabilitation. These stakeholders covered 5 continents, representing 11 global and continental rehabilitation organizations, 11 scientific journals, 4 Cochrane Networks and 3 Cochrane Groups, and included invited experts, and representatives of low middle income countries (LMICs) and consumers. We had a 70% to 82.5% response rate to the three Delphi rounds, during which participants responded to all items (100%) and provided relevant comments (range 5.5-50% per item). This participation led to several refinements to the rehabilitation definition through three preliminary versions, and the final items reached an agreement between 88.9% and 100%. We structured the definition using the PICO (Population, Intervention, Comparison, Outcome) framework. We concluded that "In a health care context," rehabilitation is defined as a "multimodal, person-centered, collaborative process" (Intervention-general), including interventions targeting a person's "capacity (by addressing body structures, functions, and activities/participation) and/or contextual factors related to performance" (Intervention-specific) with the goal of "optimizing" the "functioning" (Outcome) of "persons with health conditions currently experiencing disability or likely to experience disability, or persons with disability" (Population). Rehabilitation requires that all the items of the definition are satisfied. We defined a "rehabilitation intervention" as "any intervention provided within the rehabilitation process." We developed a rehabilitation definition for research purposes achieving a broad agreement with global stakeholders. This definition provides explicit criteria to define rehabilitation. Using the proposed definition will improve rehabilitation research by standardizing the description of interventions. Our definition may require revision in the future, as further research enhances understanding and communication of the essence and complexity of rehabilitation.

We thank Gerold Ebenbichler, Thomas Bochdansky, Kurt Ammer and Alexander Lechner for their constructive comments and thought-provoking questions about our paper, and for recognizing the novelty of our research. We hope that the following response addresses their comments and questions. We all support the use of the International Classification of Functioning, Disability and Health (ICF) in assessing functioning of patients with low back pain (LBP) in primary care. However, Ebenbichler and colleagues question the need for an ICF core set developed for manual medicine (called ManMed Set in our paper). They consider the existing ICF core set for LBP [1] as sufficient and referred to the ManMed Set as a profession-specific core set. Regarding the latter, manual medicine is not profession-specific. In our paper, we explicitly identified health professionals of diverse disciplines, such as physio/physical therapists, chiropractors, manual medicine physicians, osteopaths and naprapaths, who provide manual medicine care around the world. Consequently, a multi-professional group of manual medicine experts was involved in the development of the ManMed Set [2] because the ManMed Set was developed for use by professionals of different disciplines/specialties. Furthermore, unlike in the ManMed Set project [3], the development of the LBP core set did not involve focus groups of patients; thus, the patient’s perspective may be underrepresented in the LBP core set. In any case, as mentioned in the conclusions of our paper, the ManMed Set is intended for the assessment and reporting of functioning not only for LBP patients but for all manual medicine patients. We therefore included the categories of the ICF Generic-30 Set [4] and the Delphi study conducted in a previous manual medicine core set project [5] in the candidate ICF category list that served as the starting point for deciding on the ManMed Set. We focused on LBP patients as a case in point as this is the most common patient population treated by manual medicine practitioners [6,7]. We also wanted to highlight any differences between a generic set specific for LBP [1] and one for use in more encompassing manual medicine because patients who seek care from manual therapists may differ from other patients with LBP [8]. Since the ManMed Set does comprise a broader spectrum of categories (i.e., more activity and participation categories and environmental factors) than the LBP core set, the results seem to point to its potential use in a manual medicine population beyond LBP. The ManMed Set does not diminish in any way the value of the ICF core set for LBP. Irrespective of whether the ManMed Set could be considered what Ebenbichler and colleagues call an "ICF disability core set for LBP", the ManMed Set could serve as the basis for developing a screening tool for primary care to assess a LBP patient’s need for rehabilitation. Possible utility of a manual medicine core set in primary care was recognized by the investigators of the previous manual medicine core set project as they included general practitioners as participants of the Delphi study [5]. To explore the utility of the ManMed Set and derived tools in primary care and in other application areas, further research is warranted. Ebenbichler and colleagues note that b735 Muscle tone functions is not part of the ManMed Set. We agree that b735 is a valuable body function to consider in the assessment and reporting of patient functioning, however, it did not make the cut-off applied during the multi-professional consensus conference. Apparently, participants deemed muscle tone functions to be important, as they kept the category in the inclusion list up to the very last part of the consensus process. Here participants ranked the categories according to their importance and then a cut-off calculation was applied to the final ranking to reduce the number of categories in the ManMed Set to ensure feasibility of use. Moreover, the validity and reliability of assessing muscle tone in the lumbar spine is not established. Thus, despite recognizing the importance of muscle tone functions in manual medicine, the participants ranked it below the cut-off. We acknowledge that such a cut-off may be a drawback of the established process [2,9], but the trade-off to foregoing a cut-off may be a very large set of categories. As with all first versions of an ICF set, the ManMed Set should be validated, including the examination of possible missing essential categories, and updated accordingly. Lastly, Ebenbichler and colleagues opened a discussion about the definition for manual medicine provided in our paper. Clearly, our description does not do justice to the complexity and nuances of manual medicine; however, a more extensive description would have gone beyond the scope of the paper. We are, therefore, grateful that Ebenbichler and colleagues in their commentary filled the information gaps in our description. Ebenbichler, Bochdansky, Ammer and Lechner close by highlighting the need for a patient-oriented and functioning-based standardized tool that can be used by various practitioners across professional lines, which was exactly our impetus for initiating the project to develop the ManMed Set and the subsequent ICFbased assessment schedule for manual medicine. As such, the ManMed Set is the first but not the last of many steps toward making this a reality.