Introduction
Tinnitus is the perception of sound without an external auditory stimulus, affecting over 740 million people globally, with more than 120 million experiencing it as a debilitating condition [1]. The consequences of tinnitus extend beyond auditory symptoms, potentially impacting emotional well-being, cognitive functioning, sleep quality, and daily activities [2,3]. Due to its subjective and heterogeneous nature, the clinical management of tinnitus requires a multidimensional, person-centered approach. Tinnitus-related symptoms are significantly shaped by environmental, personal, and social factors—such as lifestyle, family support, and societal norms [4]. These factors are encompassed within the biopsychosocial model of health [5].
A growing emphasis in healthcare has shifted toward the biopsychosocial model, which conceptualizes health as an interaction between biological, psychological, and social factors [2]. This model complements person-centered care, a clinical paradigm that prioritizes the individual’s lived experiences, values, and goals within the therapeutic process [6]. For tinnitus, this approach encourages clinicians to address not only the auditory symptoms but also the broader functional and psychosocial impact on the patient’s life.
The International Classification of Functioning, Disability and Health (ICF), developed by the World Health Organization [5], provides a universal framework for understanding and describing health in terms of functioning. It includes domains such as body functions, body structures, activities and participation, and environmental factors. By applying the ICF framework, clinicians can achieve a more structured and holistic understanding of the ways in which tinnitus affects daily functioning and well-being.
Tinnitus questionnaires are essential in capturing these subjective experiences, especially in the absence of a definitive objective test. However, many existing tools focus heavily on certain domains, such as emotional distress or hearing function, while underrepresenting others, including environmental and participation-related factors [7]. Although multiple questionnaires are often used in practice, the selection is frequently guided by clinical habit or familiarity rather than by a systematic framework.
One tool designed specifically to align with the ICF is the ICF-TINI (International Classification of Functioning, Disability and Health–Tinnitus Inventory). Developed to map directly to ICF domains relevant to tinnitus, the ICF-TINI addresses areas such as mental functions, sleep, sensory processing, and participation [7]. Despite its theoretical promise, this tool remains underutilized in clinical practice and has not been widely studied alongside more established or widely used instruments like the Tinnitus Functional Index (TFI) or Tinnitus Handicap Inventory (THI) [8,9].
This paper does not aim to compare or rank tinnitus questionnaires based on effectiveness. Instead, it presents an ICFbased mapping of widely used tinnitus questionnaires—including the ICF-TINI, THI, TFI, and others—to explore the extent to which each tool covers critical domains of functioning. By identifying areas of domain overlap and gaps, we aim to assist audiologists in selecting complementary tools that support comprehensive, patient-centered assessments. While we hypothesize that more complete ICF domain coverage could facilitate better clinical insight, this proposition remains theoretical and requires further empirical testing.
Methods
Design
This study employed a rapid review methodology to identify validated tinnitus questionnaires and analyze their alignment with the ICF. A rapid review was selected because it allows for the synthesis of available evidence within a shorter timeframe than a traditional systematic review while maintaining methodological transparency and rigor. This approach was particularly appropriate given the study’s applied clinical objective—to inform real-world assessment practices by providing a timely, evidence-informed overview of existing tinnitus questionnaires. The goal was to support clinical decision-making at the assessment stage by mapping questionnaire content to ICF domains. The study focused solely on intake assessment and did not assess the impact of these tools on treatment or intervention outcomes. A rapid review approach was selected to enable timely synthesis of available evidence while maintaining methodological rigor and transparency [10]. The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [11], with adaptations appropriate to the rapid review context.
Search strategy
The literature search was conducted using PubMed, Scopus, and Google Scholar, covering published studies. Keywords included combinations of “tinnitus questionnaire,” “tinnitus assessment,” “tinnitus impact,” and “tinnitus and ICF.” Reference lists of included articles were also hand-searched to identify additional relevant publications.
Eligibility criteria
Studies were included if they were published in peer-reviewed journals in English and described the development, validation, or clinical use of tinnitus-specific questionnaires. To be eligible, questionnaires had to be tinnitus-specific instruments designed to assess the functional, emotional, cognitive, psychosocial, or participation-related impact of tinnitus. As the purpose of this review was to explore questionnaire content through the lens of the ICF, all eligible tinnitus-specific questionnaires were subsequently mapped to ICF categories using established linking rules. The ability to link questionnaire content to the ICF was therefore not used as an inclusion criterion, but rather formed part of the analytical process. Studies were excluded if they focused solely on the physiological mechanisms of tinnitus without referencing questionnaire-based assessment. Non-peer-reviewed materials such as editorials, opinion pieces, and conference abstracts were not considered.
Study selection and questionnaire identification
A single reviewer conducted the initial screening of titles and abstracts to identify studies that met the inclusion criteria. To minimize bias and enhance reliability, a second reviewer independently verified a random 20% of included and excluded records. Full-text articles that met the criteria were reviewed in detail to identify eligible tinnitus questionnaires.
Questionnaires were retained for analysis if they were specifically designed to assess the impact of tinnitus on individuals, had been validated in clinical or research settings, and contained content that could be systematically linked to ICF categories using established linking rules. In cases where multiple versions of the same instrument existed—such as short versus long forms—the version most frequently cited in the literature was selected for inclusion in the analysis. Where full and abbreviated, short-form, or revised versions of a questionnaire were identified, these were retained as separate instruments when they had been independently developed, validated, or used in clinical and research settings. This approach was adopted because abbreviated and revised versions may differ in item content, domain coverage, and clinical application, potentially influencing their mapping to ICF categories.
Linking the questionnaires to the ICF
The selected tinnitus questionnaires were systematically linked to the ICF using the refined 10-step linking rules by Cieza, et al. [29], which allow for structured mapping of health-related concepts to the ICF classification system. The linking process involved the following steps:
1) Familiarization with the ICF and the Tinnitus Questionnaires: The ICF framework and the content of each tinnitus questionnaire were reviewed to understand the constructs being measured.
2) Identification of Concepts within Each Questionnaire Item: Each item in the questionnaires was analyzed to identify the underlying concepts related to health, functioning, and disability.
3) Assignment of ICF Categories to Each Concept: The identified concepts were linked to the most appropriate ICF categories. This involved selecting the most specific ICF category that captured the essence of the concept.
4) Handling of Multiple Concepts within a Single Item: When a single item included multiple concepts, each concept was linked to a separate ICF category.
5) Use of the ICF Hierarchical Structure: Concepts were linked at the most detailed level of the ICF classification (e.g., second-level or third-level categories) to ensure specificity.
6) Handling of Concepts Not Covered by the ICF: Concepts that did not have a corresponding ICF category were documented as “not covered” by the ICF.
7) Review and Refinement of the Initial Linking: The initial linking was reviewed and refined by raters to ensure accuracy and consistency.
8) Calculation of Agreement among Raters: The inter-rater agreement was calculated using the kappa statistic to ensure the reliability of the linking process.
9) Resolution of Discrepancies: Any discrepancies between raters were resolved through discussion and consensus.
10) Documentation and Reporting of the Linking Process: The final linking, including the ICF categories assigned to each questionnaire item, was documented and reported. This linking process was conceptual in nature and aimed at content analysis rather than psychometric evaluation.
Data analysis
The linked ICF categories were analyzed to evaluate the breadth and focus of each questionnaire in terms of domain coverage. This analysis included the following: 1) domain coverage analysis, which categorized the ICF domains (e.g., body functions and environmental factors) covered by each tool; 2) frequency analysis, which examined how often specific ICF categories were referenced across all tools; and 3) gap analysis, which identified underrepresented domains, such as environmental factors and participation, to highlight areas requiring supplementary assessment. The mapping results are presented in Table 2, which lists the ICF categories assigned to each tool. Figures and supplementary questions were developed to illustrate coverage and propose ways to fill domain gaps.
Results
A total of 368 records were identified across the selected databases. After removing 82 duplicates and excluding 185 articles based on title and abstract screening, 101 full-text articles were reviewed. Of these, 70 were excluded for not meeting the inclusion criteria, resulting in a final sample of 31 studies. These studies formed the basis for identifying and analyzing validated tinnitus questionnaires, which were subsequently linked to the ICF framework. A summary of the selection process is illustrated in Fig. 1 (PRISMA flow diagram).
The content analysis revealed that the included tinnitus questionnaires varied considerably in terms of their coverage of ICF domains. No single questionnaire encompassed all relevant ICF domains—particularly the domains of environmental factors and participation. However, several instruments demonstrated broader coverage than others. The ICF-TINI provided relatively comprehensive coverage across multiple domains (Table 2), including attention and psychological functions (b1400, b1263, b1266), emotional stability (b1522), and sleep-related functions (b1341, b1342) under the domain of body functions. Although its alignment with the ICF framework was strong, body structures remained unrepresented and environmental factors were less extensively covered than body functions and activities and participation.
Furthermore, despite its coverage, the ICF-TINI remains underutilized in clinical practice, likely due to its recent development and limited dissemination.
Other well-established instruments, such as the THI and TFI, also demonstrated meaningful domain coverage, particularly across emotional, cognitive, hearing, and sleep domains. However, they lacked specific items addressing participation in social, occupational, or recreational contexts, as well as the influence of environmental barriers or facilitators.
In contrast, tools such as the Tinnitus Catastrophizing Scale (TCS) and Mini-Tinnitus Questionnaire (Mini-TQ) were more narrowly focused. These instruments predominantly assessed emotional distress (e.g., b152: emotional functions, b1521: sadness, b1522: irritability), offering targeted insights into psychological burden but omitting broader aspects of functioning such as activities, participation, or contextual influences. We included these emotionally focused questionnaires intentionally to capture the full range of instruments commonly used in clinical and research contexts, even those with a restricted conceptual scope. This inclusion enables meaningful comparison with multidimensional tools whilst highlighting the potential limitations of relying solely on such scales when attempting to assess tinnitus from a comprehensive, biopsychosocial perspective.
Table 3 presents the ICF codes linked to each questionnaire, organized by domain. The majority of questionnaires included items related to body functions—particularly mental and sensory functions—while coverage of activities and participation, environmental factors, and body structures was more limited or absent. Frequencies of domain coverage revealed that body functions were represented in nearly all instruments, whereas environmental and structural components were the least addressed.
To illustrate potential coverage gaps, Table 4 provides a list of example questions aligned with underrepresented ICF domains, particularly environmental factors and participation. These supplementary questions are intended to support clinicians in exploring these dimensions during intake assessments, particularly in cases where standardized tools are insufficiently comprehensive.
In summary, the findings demonstrate that while several tinnitus questionnaires align partially with the ICF framework, none offer full domain coverage. This suggests that intentional selection and combination of tools may be necessary to ensure a comprehensive, patient-centered assessment of tinnitus impact.
Discussion
This review highlights the variability in ICF domain coverage among tinnitus-specific questionnaires and underscores the value of an intentional, structured approach to tool selection in clinical assessment. While multiple questionnaires demonstrated alignment with various ICF domains—particularly body functions such as emotional and cognitive functioning—no single instrument fully captured the range of domains defined by the ICF, especially those related to environmental factors and participation. The ICF-TINI, TFI, and THI demonstrated broader domain representation than many of the more narrowly focused questionnaires. However, their utility is constrained by gaps in certain areas and their limited clinical uptake. This underscores the importance of understanding each questionnaire’s domain-specific strengths and limitations, rather than assuming any one instrument provides a comprehensive depiction of the patient’s experience.
In interpreting these findings, it is also useful to consider the relative uptake of different questionnaires in clinical and research contexts during the review period. Instruments such as the THI and TFI were among the most frequently used and widely cited tools, reflecting their long-standing integration into both clinical protocols and outcome research. By contrast, more targeted instruments such as the Mini-TQ and TCS appeared less frequently, often serving specialized roles in assessing emotional burden or coping responses. The ICF-TINI, while conceptually robust and highly aligned with the ICF framework, remains relatively underutilized—likely due to its recent development and limited dissemination in clinical practice. Including tools with varied degrees of uptake in this analysis was intentional, as it allows for a more comprehensive view of the current assessment landscape and highlights opportunities for broader implementation of ICF-aligned instruments.
Most questionnaires examined in this review emphasized the psychological and auditory dimensions of tinnitus but gave limited attention to participation in daily activities and environmental context, both of which are integral to the ICF model. Individuals with clinically significant tinnitus often experience difficulties that affect their daily activities and participation [7]. Manchaiah, et al. [30] found that the ICF-coded responses from individuals with tinnitus revealed that it affects a wide range of areas, including not only bodily functions but also limitations in activities and restrictions in participation. These underrepresented domains may include social engagement, occupational roles, environmental noise exposure, or access to support systems—all factors that can influence the lived experience of tinnitus. Without adequate representation of these areas, clinicians may miss critical contextual information necessary for fully understanding the patient’s condition and functional challenges. Mantello, et al. [31] found that individuals with tinnitus noted its impact on their quality of life, specifically relating to emotional and functional aspects.
Contrary to common clinical practice where multiple questionnaires are used based on availability or clinician preference, this review suggests a more strategic, domain-driven approach. Using more than one questionnaire is preferable, but understanding the design and intended purpose of the questionnaire is important in determining how appropriate it is for clinical use [32]. By combining questionnaires with complementary ICF domain coverage, audiologists can generate a more complete profile of a patient’s functioning. The perspective of functioning is crucial for individuals seeking health care, as it serves as a key indicator of treatment outcomes [5]. For example, a combination of the TFI or THI with a more ICF-aligned tool such as the ICF-TINI may help address both emotional burden and participation limitations, while also identifying environmental barriers.
It is important to clarify that the mapping process used in this study was conceptual, based on established linking rules rather than empirical testing or validation of tool performance. The analysis was conducted to explore domain coverage, not to rank or determine the clinical superiority of individual questionnaires. The use of multiple intake tools does not, in itself, guarantee effective management of tinnitus, even the most comprehensive intake assessment may fail to improve outcomes without appropriate clinical expertise, counseling, or understanding of tinnitus mechanisms.
To support clinicians in addressing overlooked domains, Table 4 provides examples of questions derived from ICF categories such as environmental factors and participation. These are not intended as replacements for standardized instruments but rather as supplementary probes to guide deeper exploration during intake interviews—particularly in cases where conventional tools may fall short.
Finally, although the ICF-TINI is a recent contribution to the field and remains relatively unknown, its alignment with the ICF framework positions it as a potentially valuable addition to the clinician’s toolkit. Greater awareness and training on the use of ICF-aligned assessments may support more context-sensitive, patient-centered care. However, further research is required to determine whether broader ICF coverage meaningfully enhances treatment planning, patient engagement, or long-term outcomes.
While this study did not seek to rank tinnitus questionnaires, it is useful to briefly reflect on the strengths and limitations of the ICF-TINI from both clinical and research perspectives. Clinically, the primary strength of the ICF-TINI lies in its broad coverage of ICF domains, allowing clinicians to capture a multidimensional profile of tinnitus impact that extends beyond auditory symptoms to include emotional, cognitive, social, and environmental aspects. This holistic perspective supports more comprehensive care planning, facilitates interdisciplinary collaboration, and may guide more tailored interventions. However, the tool’s clinical uptake remains limited, partly due to its relative novelty, the need for clinician training in ICF-based assessment, and potentially longer administration time compared to more familiar instruments.
From a research standpoint, the ICF-TINI offers a theoretically robust framework for exploring the biopsychosocial dimensions of tinnitus and for comparing functional outcomes across studies. Its standardized ICF-based structure can also enhance data comparability and support cross-disciplinary research. Nevertheless, the evidence base for its psychometric performance remains limited, and further validation in diverse populations and contexts is needed. Future studies should examine its sensitivity to change, clinical utility in longitudinal monitoring, and predictive value for treatment outcomes.
Clinical Implications
The findings of this review have several practical implications for clinicians conducting tinnitus assessments. First, they reinforce the importance of viewing tinnitus not solely as an auditory symptom but as a multifaceted condition that can impact emotional, cognitive, social, and environmental domains. Relying on a single questionnaire risks overlooking key aspects of the patient’s experience. Therefore, clinicians are encouraged to adopt a strategic approach to tool selection—choosing combinations of questionnaires that, together, provide broader coverage of the ICF domains most relevant to each patient.
Instruments such as the TFI, THI, and ICF-TINI each offer distinct domain strengths [33,34]. When comprehensive assessment is warranted, combining tools that target different domains—such as body functions, activities and participation, and sleep—may offer a more complete picture of the patient’s functioning, without skewing the impact of tinnitus toward any one domain [7]. However, clinicians should be aware that even the most broadly aligned questionnaires seldom cover domains related to environmental factors (e.g., sound exposure, social support, work context) or social participation. These omissions may leave significant contextual factors unassessed.
In cases where specific issues such as emotional distress, sleep disturbance, or cognitive interference are the primary concerns, more targeted tools (e.g., the TCS) may be useful. These tools can complement broader assessments when integrated intentionally rather than used in isolation. Beyond tinnitus-specific instruments, clinicians working in interdisciplinary or referral-based contexts may benefit from including intake tools from related domains, such as the Patient Health Questionnaire-9 (PHQ-9) for depression, Generalized Anxiety Disorder-7 (GAD-7) for anxiety, or the Insomnia Severity Index (ISI).
The application of ICF-based domain mapping can also support interprofessional collaboration. For example, if a tinnitus assessment reveals limitations in social participation or the presence of environmental stressors, this may prompt referral to a psychologist, social worker, or occupational therapist. Similarly, questions addressing sensory adaptation and balance may indicate the need for audiological or vestibular rehabilitation.
Ultimately, clinicians are advised to move beyond simply “using multiple questionnaires” toward intentional, domain-informed tool selection. This approach can enhance the relevance and completeness of intake assessments, provide a stronger foundation for shared clinical decision-making, and better align with patient-centered principles of care. While more research is needed to determine the relationship between ICF domain coverage and treatment outcomes, the current findings support the utility of ICF mapping in designing more individualized and context-sensitive assessments for patients with tinnitus.
Limitations
This study presents a conceptual analysis of ICF domain coverage across tinnitus questionnaires rather than an empirical evaluation of clinical outcomes. While the linking process followed standardized methodology, the classification of questionnaire content to ICF domains was interpretive in nature and relied on expert judgment. Although inter-rater reliability was established using Cohen’s kappa, inherent subjectivity in linking decisions may still influence the results.
Another limitation stems from the use of a rapid review methodology, which prioritizes timeliness over exhaustive coverage. While efforts were made to maintain rigor through partial verification and adherence to PRISMA guidelines, the streamlined screening and data extraction process may have excluded relevant studies or questionnaires not indexed using the selected search terms. Additionally, the review was restricted to articles published in English, which may have limited the inclusion of validated tools developed in non-English-speaking contexts.
The scope of the review focused exclusively on assessment tools and therefore does not explore how ICF alignment may influence intervention outcomes, treatment efficacy, or long-term patient satisfaction. Although we propose that broader ICF domain coverage may enhance the comprehensiveness of clinical intake, this remains a hypothesis requiring further empirical validation.
Finally, some validated tinnitus instruments—such as the Sound Exposure and Tinnitus Management Questionnaire (SETMQ), the Tinnitus-Specific Quality of Life Instrument (TS-QoL), and the Fear of Tinnitus Questionnaire (FTQ)—were not captured in the final analysis due to limitations in keyword-based searching or availability of the questionnaire at the time of the search. Future studies should include these tools in ICF-mapping exercises to offer a more inclusive representation of current clinical instruments.
Conclusions
This review provides a structured analysis of how tinnitus questionnaires align with the ICF framework. While several tools—such as the ICF-TINI, TFI, and THI—demonstrated broad domain coverage, no single questionnaire addressed all relevant aspects of functioning, particularly with regard to environmental factors and social participation. These findings highlight the limitations of relying on any one instrument and support a more strategic, domain-informed approach to tool selection.
We do not suggest that comprehensive ICF alignment guarantees improved patient outcomes. Rather, we propose that awareness of ICF domain coverage can help clinicians design more individualized assessments that are better suited to each patient’s specific challenges and goals. This may also enhance interdisciplinary collaboration by revealing areas of functioning that fall outside the audiologist’s scope and warrant referral.
Future research should investigate whether broader ICF domain representation in intake assessments contributes to improved treatment planning, greater patient engagement, or more effective long-term management. Additionally, validation studies comparing the clinical utility of ICF-aligned versus traditionally used questionnaires may further inform the role of the ICF framework in tinnitus care.
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