Eleven survey instruments were identified, of which nine were evaluated on participation. All of the nine instruments measure participation to some extent. The two instruments closest to solely involve items on participation level are the Perceived Handicap Questionnaire (PHQ) and the London Handicap Scale (LHS). The PHQ is measuring the perception of participation. In the LHS, the items are formulated in terms of participation, while the response categories include all components of the ICF, from problems in body function to participation. Much more discussion is needed to be able to get an unambiguous picture to distinguish between activity and participation.

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The GALI performs appropriately against other health indicators and appears to reflect long-standing activity limitation associated with both mental and physical conditions.

IMPACT-S is a reliable and valid generic measure of activity limitations and participation restrictions that fits the ICF.

There is a need for a new ICF scheme, better reflecting the ICF framework, for further (inter)national consideration. These Dutch schemes should be reviewed on a global scale, to develop a scheme that is more consistent with current and foreseen developments and changing ideas on health. Implications for Rehabilitation We propose policy makers on community, regional and (inter)national level to consider the use of the alternative schemes of the International Classification of Functioning, Disability and Health within their plans to promote functioning and health of their citizens and researchers and teachers to incorporate the alternative schemes into their research and education to emphasize the biopsychosocial paradigm. We propose to set up an international Delphi procedure involving citizens (including patients), experts in healthcare, occupational care, research, education and policy, and planning to get consensus on an alternative scheme of the International Classification of Functioning, Disability and Health. We recommend to discuss the alternatives for the present scheme of the International Classification of Functioning, Disability and Health in the present update and revision process within the World Health Organization as a part of the discussion on the future of the International Classification of Functioning, Disability and Health framework (including ontology, title and relation with the International Classification of Diseases). We recommend to revise the definition of personal factors and to draft a list of personal factors that can be used in policy making, clinical practice, research, and education and to put effort in the revision of the present list of environmental factors to make it more useful in, e.g., occupational health care.