Narrative Review

The IASP classification of chronic pain for ICD-11:

functioning properties of chronic pain
Boya Nugrahaa, Christoph Gutenbrunnera, Antonia Barkeb, Matthias Karstc, Jörg Schillera, Peter Schäfera,
Silke Faltera,d, Beatrice Korwisib, Winfried Riefb, Rolf-Detlef Treedee,*, The IASP Taskforce for the Classification of
Chronic Pain

Abstract
Physical, mental, and social well-being are part of the concept of health according to the World Health Organization, in addition to the
absence of disease and infirmity. Therefore, for a full description of a person’s health status, the International Classification of
Functioning, Disability and Health (ICF) was launched in 2001 to complement the existing International Classification of Diseases
(ICD). The 11th version of the ICD (ICD-11) is based on so-called content models, which have 13 main parameters. One of them is
Downloaded from http://journals.lww.com/pain by BhDMf5ePHKbH4TTImqenVM+rzkOt3HMmWlUOEUBgEnyutoH30QL1a4YN14WZhnil on 01/21/2019

functioning properties (FPs) that, according to the WHO, consist of the activities and participation components of the ICF. Recently,
chronic pain codes were added to the 11th edition of the ICD, and hence, a specific set of FPs for chronic pain is required as a link to
the ICF. In addition, pain is one of the 7 dimensions of the generic set of the ICF, which applies to any person. Thus, assessment and
management of pain are also important for the implementation of the ICF in general. This article describes the current consensus
proposal by the International Association for the Study of Pain (IASP) and the International Society of Physical and Rehabilitation
Medicine (ISPRM) for a specific set of FPs of chronic pain, which will have to be empirically validated in a next step. The combined use
of ICD-11 and ICF is expected to improve research reports on chronic pain by a more precise and adequate coding, as well as
patient management through better diagnostic classification.
Keywords: Classification, Chronic pain, ICF, Functioning, Core set, Disability, Rehabilitation

1. Introduction International Classification of Functioning, Disability and Health

The World Health Organization (WHO) defines health as a “state
of complete physical, mental, and social well-being and not
merely the absence of disease and infirmity.”18 The International
Classification of Diseases (ICD) was originally developed from
a list of causes of death,16 concentrating on the latter part of the
WHO definition of health: absence of disease and infirmity.13 For
that reason, the use of the ICD alone is insufficient to provide a full
description of a person’s health status. The launch of the
Sponsorships or competing interests that may be relevant to content are disclosed
at the end of this article.
B. Nugraha, C. Gutenbrunner, and A. Barke also contributed equally to the
manuscript; R.-D. Treede and W. Rief also contributed equally.
a
Department of Rehabilitation Medicine, Hannover Medical School, Hannover,
Germany, b Clinical Psychology and Psychotherapy, Philipps-University Marburg,
Marburg, Germany, c Department of Anesthesiology and Intensive Care Medicine,
Pain Clinic, Hannover Medical School, Hannover, Germany, d Institute of General
Practice, Hannover Medical School, Hannover, Germany, e Department of
Neurophysiology, CBTM, Medical Faculty Mannheim of Heidelberg University,
Mannheim, Germany
*Corresponding author. Address: Department of Neurophysiology, Centre for
Biomedicine and Medical Technology Mannheim, Medical Faculty Mannheim,
Heidelberg University, Ludolf-Krehl-Str.13-17, 68167 Mannheim, Germany.
Tel.: 149 (0)621 383 71 400; fax: 149-(0)621 383 71 401. E-Mail address:
Rolf-Detlef.Treede@medma.uni-heidelberg.de (R.-D. Treede).
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article on
the journal’s Web site (www.painjournalonline.com).
PAIN 160 (2019) 88–94
© 2018 International Association for the Study of Pain
http://dx.doi.org/10.1097/j.pain.0000000000001433
(ICF) by the WHO in the year 2001 led to a paradigm shift towards
describing health in a more comprehensive way and including
aspects of physical, mental, and social well-being.19 Since then,
the term “functioning” has been used to describe the interaction
of a person with a health condition with the environment,
including both capacity and performance. This was a major step
towards an operationalization of the WHO’s definition of health.19
With the purpose of achieving a more comprehensive picture of
a person’s health, the WHO decided to integrate the so-called
“functioning properties” (FPs) as one of the main parameters of
the content model in the 11th revision of the ICD (ICD-11).20
Content models are the standardized basis for each entry of the
ICD-11, ensuring that each entity is well-defined and based on
current scientific knowledge. The inclusion of FPs in the content
models means that the ICF has been integrated with the new
ICD.12
The WHO has defined a generic set of 7 dimensions of
functioning; these dimensions are similar to the dimensions of
quality-of-life scores, of which the presence or absence of pain is
one. Thus, assessment and management of pain are important
considerations in the context of applying the ICF to any health
condition.
Recently, chronic pain codes (several classes of pain that
persists or recurs longer than 3 months) were added to the 11th
edition of the ICD,15 and hence, a specific set of FPs for chronic
pain is required as a link to the ICF.20 Increased attention to the
functional impact of chronic pain is an important step forward for
its management. The existence of useful codes in ICD and ICF is
a necessary condition but will hardly be sufficient to improve
patient care, unless these codes are used in clinical practice.

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Figure 1. The International Classification of Functioning, Health and Disease (ICF) framework (with permission from the WHO).19

Introduction of a predecessor code into the German variant of
ICD-10 in 2009 (F45.41) had a major impact on clinical practice by
becoming the prime indication for multimodal pain management
and directing funding towards its reimbursement since 2013.11
The development of a proposal of FPs for chronic pain in the
ICD and the ICF is within the framework of a memorandum of
understanding between the International Association for the
Study of Pain (IASP), an organization that leads the professional
forum for science, practice, and education in the field of pain, and
the International Society of Physical and Rehabilitation Medicine
(ISPRM), a world organization active in the field of rehabilitation
including aspects of functioning in the light of health conditions.
This article describes the process and the result of the
development of FPs, specifically for chronic pain.
the environment (Fig. 1). Functioning consists of the factors body
functions and structures, and activities and participation (Fig. 1).
In this context, participation is defined as the involvement of
a person in a life situation. The ICF also highlights the relevance of
contextual factors acting as facilitators or barriers for functioning,
which reflect either positive or negative aspects, respectively.
They are grouped in the environmental and personal factors
(Table 1).19
Besides the conceptual framework to describe the experience
of functioning and disability, the ICF includes a classification with
more than 1400 domains in the components body functions (8
chapters), body structures (8 chapters), activities and participa-
tion (9 chapters), and environmental factors (5 chapters). The
personal factors are not classified in the ICF.

2.2. The components of the ICF

2. The International Classification of Functioning,
Disability and Health
2.1. Definition
The ICF is a framework to describe health and health-related
states.19 It is one of the international classifications developed by
the WHO to be applied in various aspects of health care with the
goal of providing a unified and standard language and framework
for the description of health and health-related states.19
Considering the fact that people with one and the same clinical
condition can vary substantially in terms of disability, this
extension to the use of diagnoses was a necessity. One of the
core concepts of the ICF is to describe functioning and disability
as an interaction between a person with a health condition and
The components of the ICF are defined as follows19 (Table 1):
(1) Body functions are the physiological functions of body
systems (including psychological functions).
(2) Body structures are anatomical parts of the body such as
organs, limbs, and their components.
(3) Impairments are problems in body function or structure such
as a significant deviation or loss.
(4) Activity is the execution of a task or action by an individual.
(5) Participation is a person’s involvement in a life situation.
(6) Activity limitations are difficulties an individual may have in
executing activities.
(7) Participation restrictions are problems an individual may
experience in involvement in life situations.

Table 1
An overview of the components of the Classification of Functioning, Health and Disease (with permission from WHO).15
Components Part 1: Functioning and disability Part 2: Contextual factors
Body functions and structures Activities and participation Environmental factors Personal factors
Domains Body functions and structures Life areas (tasks and actions) External influences on functioning Internal influences on functioning
and disability and disability
Constructs Change in body functions (physiological) Capacity; executing tasks in a standard Facilitating or hindering impact of Impact of attributes of the person
and change in body structures environment; performance; and executing features of the physical, social, and
(anatomical) tasks in the current environment attitudinal world
Positive Functioning
aspect Functional and structural integrity Activities and participation Facilitators Not applicable
Negative Disability
aspect Impairment Activity limitation and participation restriction Barriers/hindrances Not applicable

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Table 2
List of functioning properties for chronic pain: ICF components "body functions" and "body structures".
ICF domains ICF code Comprehensive CWP core set Brief CWP core set Generic set FPs chronic pain (consensus)
Body functions
Global psychosocial functions b122 X
Temperament and personality functions b126 X
Energy and drive functions b130 X X X X
Sleep functions b134 X X X
Attention functions b140 X X
Psychomotor functions b147 X X
Emotional functions b152 X X X X
Content of thought b1602 X X
Higher-level cognitive functions b164 X
Experience of self and time functions b180 X
Proprioceptive function b260 X
Touch functions b265 X
Sensory functions related to temperature and b270 X
other stimuli
Sensation of pain b280 X X X X
Haematological system functions b430 X
Exercise tolerance functions b455 X X X
Sexual functions b640 X
Mobility of joint functions b710 X X
Muscle power functions b730 X X X
Muscle tone functions b735 X
Muscle endurance functions b740 X
Control of voluntary movement functions b760 X X
Sensations related to muscles and movement b780 X
functions
Body structures
Additional musculoskeletal structures related s770 X
to movement
Number of included codes 24 9 3 8
The section “body functions and structures” is not included in the ICD-11.
CWP, chronic widespread pain; FPs, functioning properties.19

(8) Environmental factors make up the physical, social, and
attitudinal environment in which people live and conduct their
lives.
Within the ICF framework, “functioning” is an umbrella term
encompassing all body functions, activities, and participation,
whereas “disability” is defined as an umbrella term for impair-
ments, activity limitations, and participation restrictions.19 To
facilitate the use of the ICF, so-called “core sets” were developed.
A core set for a health condition X is a list of essential categories
that are relevant for the description of the functioning of a person
with condition X.
2.3. Representation of pain in ICF
In the ICF, pain is classified as a body function together with other
sensory functions (Chapter 2 of body functions).19 The sensation
of pain is described as “sensation of unpleasant feeling indicating
potential or actual damage to some body structure” and includes
“sensations of generalized or localized pain, in one or more body
parts, pain in a dermatome, stabbing pain, burning pain, dull pain,
aching pain, and impairments such as myalgia, analgesia, and
hyperalgesia.”19 Please note that this definition in the ICF is close
to, but not identical with, the IASP definition.8 Specifically, it
implies a close link between the sensation of pain and the
presence of a noxious stimulus (observable from a third person
perspective), whereas the IASP definition is from a first person
perspective and clarifies that anything that feels like pain is pain by
definition.14
In the ICF, pain has the following domains:
(1) Generalized pain (b2800)
(2) Pain in body part (b2801), including pain in head and neck
(b28010), pain in chest (b28011), pain in stomach or abdomen
(including pain in the pelvic region) (b28012), pain in back
(including pain in the trunk; low backache) (b28013), pain in
upper limb (including hands) (b28014), pain in lower limb
(including feet) (b28015), pain in joints (including small and big
joints) (b28016), as well as pain in body part, other specified,
(b28018), and pain in body part, unspecified, (b28019)
(3) Pain in multiple body parts (b2802)
(4) Radiating pain in a dermatome (b2803)
(5) Radiating pain in a segment or region (b2804).
The ICF also includes the domain sensation of “pain, other
specified and unspecified” (b289), “sensory functions and pain,
other specified” (b298), and “sensory functions and pain,
unspecified” (b299).
This view of pain as a limitation to functioning according to its
location needs to be differentiated from the categorical diagnoses
of chronic pain according to its etiology listed in the ICD-11.
Within the ICD-11, chronic pain as a symptom (ie, chronic pain
related to a specific disease) is distinguished from pain as
a syndrome (ie, chronic pain as a problem in its own right). In the
ICD-11 classification of chronic pain, “pain as a symptom” applies
to chronic secondary pain syndromes, including secondary
headaches, whereas “pain as a syndrome” applies to chronic
primary pain syndromes, including primary headaches.15 In both
cases, ICD-11 chronic pain conditions do not only document

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single symptoms, but also other information (eg, on etiology,
course, and intensity) and inclusion/exclusion criteria.
Pain (b280) is also part of the generic set of the ICF applicable
to all health conditions (Tables 2–4). However, the ICD-11 only
cross-references “activities and participation domains” of the
ICF.12 As part of the “body function” domains of the ICF, pain will
not be cross-referenced in the “functioning properties” of all
diagnoses in the ICD-11. Therefore, it is important that the new
ICD-11 codes for chronic secondary pain syndromes are widely
used to identify patients with chronic pain as a symptom of
cancer, trauma, disease of the nervous system or internal organs,
or the musculoskeletal system.15
3. Description of typical disabilities associated with
chronic pain
According to the ICF, disability is defined as the negative aspect
of functioning and includes the components body functions and
structures as well as activities and participation (Table 1). The
negative aspect of functioning at the level of body functions and
structures is called “impairment,” whereas at the level of activities
and participation, it is called “activity limitation” and “participation
restriction,” respectively. For that reason, the typical disabilities
associated with chronic pain should be described as impair-
ments, activity limitations, and participation restrictions.
Many chronic pain patients have typical disabilities: they
frequently experience depression, anxiety, sleep disturbance,
fatigue, and waking unrefreshed among others.2,7,9,10 Moreover,
many chronic pain patients also experience a deterioration in the
quality of life (QoL), and high rates of other disabilities.7 At the
impairment level, this includes changes in energy and drive,
sleep, psychological, and motor functions. At the level of activity
limitations and participation restriction, the most relevant areas
include mobility, coping with stress, daily routines, workplace,
recreation, family, and community life.
4. Development of a specific set of functioning
properties for chronic pain
4.1. Methodology
To reach a consensus regarding the FPs for chronic pain, the
IASP and the ISPRM referred to the existing methodology for
identifying relevant ICF domains.4,6,12 Subsequently, each
society formulated a proposal for the FP for chronic pain.
The ISPRM considered the chronic widespread pain (CWP)
core set to be the most comprehensive and relevant to generate
FPs for chronic pain. Therefore, the comprehensive and brief core
set for CWP was used. A discussion was held to reach a proposal
of FPs by involving other experts, such as anesthesiologists,
physical and rehabilitation medicine physicians, occupational
therapists, physiotherapists (PT), and pain researchers.
The IASP developed the FPs for chronic pain from the generic set
of the ICF. Then, further items that in pain experts’ opinions (including
anaesthesiologists, psychologists, neurologists, and general practi-
tioners etc.) are relevant to chronic pain were added. The added
items included sleep, cognitive functions, and self-care.
The 2 proposals (one by the ISPRM and one by the IASP) were
discussed in a consensus meeting in Kuala Lumpur during the 10th
ISPRM World Congress, on May 29, 2016. The meeting followed
a workshop format and was attended by international experts,
including physical and rehabilitation medicine physicians, anesthe-
siologist, PTs, occupational therapists, and pain researchers. A
consensus was reached regarding the FPs for chronic pain.
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www.painjournalonline.com 91
4.2. Results
The ICF already contains a core set for CWP, which is one of the
most important chronic primary pain syndromes in the ICD-11.3
This core set identified 24 domains of body functions and
structures (Table 2), 27 domains of activity and participation
(Table 3), and 16 domains of environmental factors (Table 4) as
relevant for patients with CWP.3 Assessment of all 67 domains by
trained observers would be very time-consuming, hence a subset
of these domains was selected as most relevant for CWP, which
consists of 24 domains (brief core set, see Tables 2–4).3 The
generic set of the ICF consists of 7 domains, 3 in body functions
and structures including pain (Table 2) and 4 in activities and
participation (Table 3). Initial conversations between representa-
tives of ISPRM and IASP led to the conclusion that the generic set
is insufficient for chronic pain because important domains are
missing (eg, sleep), whereas the 2 sets for CWP were assumed to
be too broad because they are designed to cover one of the most
complex chronic primary pain syndromes. During the aforemen-
tioned consensus meeting in Kuala Lumpur, a list of 17 domains
of FP was agreed. It contains 8 body functions, 7 activity and
participation domains, and 2 environmental factors (Tables 2–4).
The proposed set for chronic pain includes the following:
(1) Three domains of body functions of the generic set:
energy and drive (b130), emotional functions (b152), and
sensation of pain (b280)
(2) Five additional domains of body functions:
sleep (b134), attention (b140), exercise tolerance (b455),
mobility of joint (b710), and muscle power (b730).
(3) Four domains of activities and participation from the generic
set:
performing the daily routine (d230), walking (d450), moving
around (d455), and remunerative employment (850)
(3) Three additional domains of activities and participation:
Lifting and carrying objects (d430), intimate relationships
(d770), and recreation and leisure (d920)
(4) Two additional domains of environmental factors:
Individual attitudes of immediate family members (e410) and
social security services, systems, and policies (e570)
This result was rediscussed within the IASP and within the
ISPRM, with the understanding that a formal validation will be
necessary before the final implementation. Although the pain
codes in the ICD-11 have already undergone several field trials,
none of them so far included the FPs as listed here. According to
the reference guide of the WHO for the ICD-11,17 the FPs in the
ICD-11 will only include the “activities” and “participation”
domains (ICF code d—see also Table 3 in bold and italics):
(1) Performing daily routine (d230)
(2) Lifting and carrying objects (d430)
(3) Walking (d450)
(4) Moving around (d455)
(5) Intimate relationships (d770)
(6) Remunerative employment (d850)
(7) Recreation and leisure (d920)
5. Discussion and outlook
For the treatment and rehabilitation of patients with chronic pain,
it is of major importance to set up a clear diagnosis including the
underlying pathology and the mechanisms of chronic pain. The
distinction between chronic primary pain syndromes and
chronic secondary pain syndromes will offer better integration
with other branches of medicine when pain is predominantly the
symptom of another disease (chronic secondary pain
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Table 3
List of functioning properties for chronic pain: ICF component “activities and participation”.
ICF domains ICF code Comprehensive CWP core set Brief CWP core set Generic set FPs chronic pain (consensus)
Focusing attention d160 X
Solving problems d175 X X
Undertaking multiple tasks d220 X
Performing daily routine d230 X X X X
Handling stress/other psychological demands d240 X X
Changing basic body position d410 X
Maintaining body position d415 X
Lifting and carrying objects d430 X X X
Walking d450 X X X X
Moving around d455 X X X
Using transportation d470 X
Driving d475 X
Washing oneself d510 X
Dressing d540 X
Looking after one’s health d570 X
Acquisition of goods and services d620 X
Doing housework d640 X X
Caring for household objects d650 X
Assisting others d660 X
Complex interpersonal interactions d720 X
Family relationships d760 X X
Intimate relationships d770 X X X
Acquiring, keeping, and terminating job d845 X
Remunerative employment d850 X X X X
Nonremunerative employment d855 X
Community life d910 X
Recreation and leisure d920 X X X
Number of included codes 27 10 4 7
Highlighted in bold and italics: Functioning properties included in the ICD-11 (activities and participation).
CWP, chronic widespread pain; FPs, functioning properties.19

syndromes), while offering the lay public, and people with
chronic pain among them, help in understanding what is wrong
when chronic pain itself is the disease (chronic primary pain
syndromes).15
For the patients themselves, other factors may play an equally
important role in relation to suffering, QoL, and participation in
family and other areas of social life. These factors are recorded as
patient-reported outcome measures that become more and
more important in evaluating the quality of health care. The
multimodal pain management approach refers to a biopsychoso-
cial model of pain that directs attention to these factors.5
Extension codes for chronic pain in ICD-11 cover a range of
cognitive, behavioral, emotional, and social factors.15 The FPs of
chronic pain in ICD-11 will primarily serve to code the social part
of this model by cross-reference to the second major WHO
classification: ICF.12
The ICF has a major focus on the patient’s lived experience
with high relevance for overall health, including (1) to understand
the complex problems of patients with chronic pain, including
psychological factors, the influence of the environment or
behavioral stereotypes of the patients, and (2) focus on the
patient experiences that are not only related to the symptoms, but
the impact on daily life (which may require rehabilitation). The set
of FPs for chronic pain presented here includes aspects of daily
routines, mobility, and social interactions (partner, workplace,
and recreation). This set was developed at the level of an expert
consensus. Although it is based on results from the literature (ie,
the ICF core sets for chronic pain and other pain conditions) and
has a multiprofessional approach, its relevance must be
validated. The chronic pain codes for the ICD-11 have been field
tested on consecutive patient case series in 4 countries in 2016,1
and as part of the WHO validation of line coding and case coding
in 2017, but functional properties were not part of those field
tests. Future field tests should include aspects of feasibility and
acceptance by users as well as the relevance for patients with
chronic pain experiencing activity limitations and participation
restrictions.
From a holistic point of view, a joint use of both classifications is
recommended and will be facilitated by the integration of the ICF into
the ICD-11. The integration of disease-specific strategies (so-called
curative strategies) alongside a comprehensive approach to the QoL
and functioning (so-called rehabilitation strategy) is crucial for an

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 January 2019
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Table 4
List of functioning properties for chronic pain: ICF component “environmental factors”.
ICF domains ICF code
Drugs e1101
Immediate family e310
Acquaintances, peers, colleagues, neighbours, e325
and community members
Health professionals e355
Individual attitudes of immediate family e410
members
Individual attitude of friends e420
Individual attitudes of acquaintances, peers, e425
colleagues, neighbours, and community
members
Individual attitudes of people in position of e430
authority
Individual attitudes of health professionals e450
Individual attitude of health-related e455
professionals
Societal attitudes e460
Social norms, practices and ideologies e465
Social security services, systems, and policies e570
General social support services, systems, and e575
policies
Health services, systems, and policies e580
Labour and employment services, systems, and e590
policies
Number of included codes
The section “environment” is not included in the ICD-11.
CWP, chronic widespread pain; FPs, functioning properties.19
improved quality of care for patients suffering from chronic pain. The
integration of the FPs into the new ICD-11 will be a great step forward
to a holistic view on our patients and their needs for care (including
multimodal pain management and rehabilitation). It will lead to an
increased awareness of all health professionals regarding relevant
problems the patients are struggling with. Thus, all stakeholders,
including clinicians, patients, health insurers, and others will benefit
from the inclusion of FPs.
On the other hand, there are also risks and problems occurring
from the way FPs are included into the ICD-11. It has a re-
ductionist approach by identifying the most frequent or most
relevant domains of functioning. This ignores that activities and
participation domains are highly individual and related to many
individual and societal factors. Some of them are individual life
goals, individual and societal attitudes, cultural background,
religious, or other spiritual principles. They are also influenced by
age, sex, assets, and position in society. For that reason, the
assessment of the “most important” FPs must not replace the
individual approach to identify the domains most relevant in
the individual case.
Another limitation is the restriction of the ICD-11 functioning
properties to “activities and participation” items from the ICF. One
of the great achievements of the ICF is that it integrates body
functions and structures, activities and participation, as well as
the environmental and personal factors. For that reason, the
integration of FPs (that represent only activities and participation)
into the ICD-11 cannot replace the use of the ICF. For
Copyright Ó 2018 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
www.painjournalonline.com 93
Comprehensive CWP core set Brief CWP core set Generic set FPs chronic pain (consensus)
X X
X X
X
X X
X X X
X
X
X
X
X
X
X
X X X
X
X
X
16 5 0 2
a comprehensive view of patients’ problems, it is still necessary
to refer to the definition of disability that is in line with the ICF.
However, the extension codes for psychological and social
factors in the ICD-11 and the pain severity code including pain
intensity, distress, and disability add at least some information on
nonsymptom determinants of disability in chronic pain.
This limitation also applies to the generic core set of the ICF,
which-although it includes the sensation of pain, but as part of
body functions-this is not going to be part of the FPs for all ICD-
11 codes. Therefore, the chronic secondary pain syndrome
codes developed by the IASP will be important as codiagnoses
with an underlying disease, eg, diabetic polyneuropathy
combined with chronic peripheral neuropathic pain. A further
limitation derives from the differences in definitions of pain
between the ICF and the IASP: the ICF places an emphasis on
the sensory component of pain, whereas the affective motiva-
tional component included in the IASP definition may be more
relevant in chronic pain patients. Furthermore, it is not fully
obvious from the ICF definition that pain is defined (by the IASP)
as a subjective percept, and anything that feels like pain is pain
by definition, independent of any observable signs of nocicep-
tion.14 In conclusion, the new codes for chronic primary and
secondary pain syndromes in the ICD-11 are expected to
improve diagnostic classification as indications for individual-
ized pain management, and the integration of the ICF with the
ICD is expected to further improve a holistic view of the patient
including their functioning in everyday life.
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Conflict of interest statement
A. Barke reports personal fees from IASP, during the conduct of
the study. W. Rief reports grants from IASP, during the conduct of
the study; personal fees from Heel, personal fees from Berlin
Chemie, outside the submitted work. R.-D. Treede reports grants
from Boehringer Ingelheim, Astellas, AbbVie, Bayer, personal
fees from Astellas, Grünenthal, Bauerfeind, Hydra, Bayer, grants
from EU, DFG, BMBF, outside the submitted work. The remaining
authors have no conflict of interest to declare
Acknowledgements
The authors gratefully acknowledge the financial support by the
International Association for the Study of Pain and the excellent
discussions with Dr. Robert Jakob of the WHO.
Members of the Taskforce: Rolf-Detlef Treede (Chair), Winfried
Rief (Co-chair), Antonia Barke, Qasim Aziz, Michael I. Bennett,
Rafael Benoliel, Milton Cohen, Stefan Evers, Nanna B. Finnerup,
Michael First, Maria Adele Giamberardino, Stein Kaasa, Beatrice
Korwisi, Eva Kosek, Patricia Lavand’homme, Michael Nicholas,
Serge Perrot, Joachim Scholz, Stephan Schug, Blair H. Smith,
Peter Svensson, Johannes Vlaeyen, Shuu-Jiun Wang.
Appendix A. Supplemental digital content
Supplemental digital content associated with this article can be
found online at http://links.lww.com/PAIN/A658. SDC includes
a complete reference list of the diagnoses entered into the
foundation with the foundation IDs as well as the extension codes
(specifier). Since the complete list is contained, the material is
identical for all papers of the series.
Article history:
Received 13 June 2018
Received in revised form 22 October 2018
Accepted 24 October 2018
References
[1] Barke A, Korwisi B, Casser HR, Fors EA, Geber C, Schug S, Stubhaug A,
Ushida T, Wetterling T, Rief W, Treede RD. Pilot field testing of the chronic
pain classification for ICD-11: the results of ecological coding. BMC
Public Health 2018;18:1239.
[2] Boakye PA, Olechowski C, Rashiq S, Verrier MJ, Kerr B, Witmans M,
Baker G, Joyce A, Dick BD. A critical review of neurobiological factors
involved in the interactions between chronic pain, depression, and sleep
disruption. Clin J Pain 2016;32:327–36.
[3] Cieza A, Stucki G, Weigl M, Kullmann L, Stoll T, Kamen L, Kostanjsek N,
Walsh N. ICF core sets for chronic widespread pain. J Rehabil Med 2004;
36 (44 suppl):63–8.
[4] Escorpizo R, Kostanjsek N, Kennedy C, Nicol MMR, Stucki G, Üstün B.
Functioning topic advisory group of the ICDR. Harmonizing WHO’s
Copyright Ó 2018 by the International Association for the Study of Pain. Unauthorized reproduction of this article is prohibited.
PAIN®
International Classification of Diseases (ICD) and International
Classification of Functioning, Disability And Health (ICF): importance
and methods to link disease and functioning. BMC Public Health 2013;
13:742.
[5] Kaiser U, Treede RD, Sabatowski R. Multimodal pain therapy in chronic
noncancer pain-gold standard or need for further clarification? PAIN
2017;158:1853–185.
[6] Kohler F, Selb M, Escorpizo R, Kostanjsek N, Stucki G, Riberto M. The
International Society of Physical and Rehabilitation Medicine (ISPRM)
sub-committee implementation of the ICF and the participants of the São
Paulo ISPRM—World health Organization (WHO) workshop. Towards the
joint use of ICD and ICF: a call for contribution. J Rehabil Med 2012;44:
805–10.
[7] Lerman SF, Rudich Z, Brill S, Shalev H, Shahar G. Longitudinal
associations between depression, anxiety, pain, and pain-related
disability in chronic pain patients. Psychosom Med 2015;77:333–41.
[8] Merskey H, Bogduk N. Classification of chronic pain. Seattle: IASP Press,
1994.
[9] Nicholas M, Vlaeyen JWS, Rief W, Barke A, Aziz Q, Benoliel R, Cohen M,
Evers S, Giamberardino MA, Göbel A, Korwisi B, Perrot S, Svensson P,
Wang SJ, Treede RD; The IASP Taskforce for the Classification of Chronic
Pain. The IASP Classification of Chronic Pain for ICD-11: chronic primary
pain. PAIN 2019;160:28–37.
[10] Rayner L, Hotopf M, Petkova H, Matcham F, Simpson A, McCracken LM.
Depression in patients with chronic pain attending a specialised pain
treatment centre: prevalence and impact on health care costs. PAIN
2016;157:1472–9.
[11] Rief W, Treede RD, Schweiger U, Henningsen P, Rüddel H, Nilges P. New
pain diagnosis in the German version of the ICD-10 [in German].
Nervenarzt 2009;80:340–2.
[12] Selb M, Kohler F, Nicol MMR, Riberto M, Stucki G, Kennedy C, Üstün B.
ICD-11: a comprehensive picture of health, an update on the ICD-ICF
joint use initiative. J Rehabil Med 2015;47:2–8.
[13] Stucki G. Olle Höök Lectureship 2015: the World Health Organization’s
paradigm shift and implementation of the International Classification of
Functioning, Disability and Health in Rehabilitation. J Rehabil Med 2016;
48:486–93.
[14] Treede RD. The International Association for the Study of Pain definition of
pain: as valid in 2018 as in 1979, but in need of regularly updated
footnotes. PAIN Rep 2018;3:e643.
[15] Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, Cohen M,
Evers S, Finnerup NB, First MB, Giamberardino MA, Kaasa S, Korwisi B,
Kosek E, Lavand’homme P, Nicholas M, Perrot S, Scholz J, Schug S,
Smith BH, Svensson P, Vlaeyen JWS, Wang SJ. Chronic pain as
a symptom and a disease: the IASP classification of chronic pain for the
International Classification of Diseases ICD-11. PAIN 2019;160:19–27.
[16] World Health Organization. International Classification of Diseases (ICD)
Information Sheet. 2018. WHO. Geneva. Available at: http://www.who.int/
classifications/icd/factsheet/en/. Accessed 13 November 2018.
[17] World Health Organization. ICD-11 International Classification of
Diseases for Mortality and Morbidity Statistics. Eleventh Revision
(reference Guide Draft). Geneva: WHO, 2017.
[18] World Health Organization. Preamble to the Constitution of WHO as
adopted by the International Health Conference, New York, 19 June - 22
July 1946; signed on 22 July 1946 by the representatives of 61 States
(Official Records of WHO, no. 2, p. 100) and entered into force on 7 April
1948.
[19] World Health Organization. International Classification of Functioning,
Disability and Health: ICF. Geneva: WHO, 2001.
[20] World Health Organization. ICD-11 alpha. Content model reference
guide. Geneva: WHO, 2011.