Introduct ion in the use o f the Internat ional C lass ificat ion o f Funct ioning

( ICF) in c l in ica l management in undergraduate phys io therapy programme.

JENNIFER JELSMA

UNIVERSITY OF CAPE TOWN

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How do we decide what to do with our patients?

Introduction2

One of the most difficult skills that a physiotherapy student has to learn is clinical reasoning.

In order to meet the needs of a patient, the student needs to know what the needs are, analyse these needs and the problems that are causing them, choose and apply suitable techniques and then assess whether the intervention has been effective.

The process3

Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibitedSteiner WA, Ryser L, Huber E, et al. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther 2002; 82: 1098-1107

The Rehab-CYCLE is a modified version of the Rehabilitation Cycle developed by Stucki and Sangha.14 It guides the health care professional with a logical sequence of activities. Endpoints of this rehabilitation management system are successful problem solving or individual goals achieved. The Rehab-CYCLE involves identifying the patient’s problems and needs, relating the problems to relevant factors of the person and the environment, defining therapy goals, planning and implementing the interventions, and assessing the effects.

The Problem 4

Problem 2:How do we go about gathering this information and how do we go about analysing the information to decide on treatment goals and intervention?

A useful manner to gather the information gained during the patient assessment is to use the ICF

Problem 1:There is so much information that must be gathered some of it is not important and some ends up by being essential.

Objective of the module5

At the conclusion of the module, the student should be able to:

Describe the rehabilitation cycle Describe the components of the

International Classification of Functioning, Disability and Health. (ICF)

Describe the process of patient assessment Explain how the ICF philosophy can be used

as a framework to collect and analyse patient data and to decide on treatment priorities.

The ICF6

International Classification of Functioning Disability and Health (ICF) Official classification of WHO The International Classification of Functioning, Disability and Health, known more commonly as ICF, is a

classification of health and health-related domains. These domains are classified from body, individual and societal perspectives by means of two lists: a list of body functions and structure, and a list of domains of activity and participation. Since an individual’s functioning and disability occurs in a context, the ICF also includes a list of environmental factors.

The ICF is WHO's framework for measuring health and disability at both individual and population levels. The ICF was officially endorsed by all 191 WHO Member States in the Fifty-fourth World Health Assembly on 22 May 2001(resolution WHA 54.21). Unlike its predecessor, which was endorsed for field trail purposes only, the ICF was endorsed for use in Member States as the international standard to describe and measure health and disability. http://www.who.int/classifications/icf/en/ accessed 27/10/10

Official classification of American Physical Therapy Association

The International Classification of Functioning, Disability, and Health (ICF) is part of the 'family' of international classifications developed by the World Health Organization (WHO). The ICF classification system focuses on human functioning and provides a unified, standard language and framework that captures how people with a health condition function in their daily life rather than focusing on their diagnosis or the presence or absence of disease.

In June 2008, APTA joined the World Health Organization (WHO), the World Confederation for Physical Therapy, the American Therapeutic Recreation Association, and other international organizations in endorsing the ICF. With this endorsement, ICF language will be incorporated into all relevant association publications, documents, and communications through existing planned review and revision cycles.

Reprinted from International Classification of Functioning, Disability and Heath (ICF) with permission from the American Physical Therapy Association. Accessed at http://www.apta.org/ICF/ on 21/07/11.

Why is it special?

It is a system of classification which helps users to identify the different aspects of a person’s condition that can impact on health and functioning. It can be used to gather information in a standardised manner through the use of codes. It is also possible to use the philosophical framework to gather information and plan treatment.

Breakdown of ICF

Components of the ICF

Impairments of body structure (e.g. eye)

and function (e.g. seeing)

Activity limitation (e.g. rolling, walking, dressing)

Participation restrictions (e.g. limited access

to education, transport)

Environmental factors: (e.g. policies such as education policy

for disabled children, physical environment, available

aids, appliances

What causes disability? 19809

Impairments

Disease ordisorder

Disabilities Handicaps

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Interaction of Concepts ICF 2001

Health Condition (disorder/disease)

Environmental Factors

Personal Factors

Body function&structure (Impairment)

Activities(Limitation)

Participation(Restriction)

Based on: World Health Organisation (WHO), 2001. International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: http://www.disabilitaincifre.it/documenti/ICF_18.pdf

ICF Components11

Body Functions&

Structures

Activities &

ParticipationEnvironmental Factors

Barriers

Facilitators

Functions

Structures

Capacity

Performance

Body Functions and Structures12

Mental functions Structures of the nervous system

Sensory functions and pain The eye, ear and related structures

Voice and speech functions Structures involved in voice and speech

Functions of the cardiovascular, haematological, immunological and respiratory systems

Structures of the cardiovascular, immunological and respiratory systems

Functions of the digestive, metabolic and endocrine systems

Structures related to the digestive, metabolic and endocrine systems

Genitourinary and reproductive functions Structures related to the genitourinary and reproductive systems

Neuromusculoskeletal and movement-related functions

Structures related to movement

Functions of the skin and related structures

Skin and related structures

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Body Structures

S240 Structure of external ear

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S240 Structure of external ear

s7302 Structure of hand

Activities and Participation16

1 Learning &Applying Knowledge2 General Tasks and Demands3 Communication4 Movement5 Self Care6 Domestic Life Areas7 Interpersonal Interactions8 Major Life Areas9 Community, Social & Civic Life

Environmental Factors17

1. Products and technology 2. Natural environment and human-

made changes to the environment3. Support and relationships4. Attitudes 5. Services, systems and policies

Can assist

In identifying what is the most important areato concentrate

intervention for the patient on that day

It can assist in analysing the relationships betweenthe different aspects to

identify what are the causes and what are the effects of impairments and

functional deficits

It can be used to give an outline of all aspects of impairment and functioning

that need to be assessed

How does the ICF assist in clinical reasoning ?

Data Gathering

Analysis

Decision Making

Application of the ICF in the clinical setting

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Assessment of children with neurological problems

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DEMOGRAPHIC DETAILS NAME: ASSESSED BY:DATE OF BIRTH: DATE OF ASSESSMENT:AGE:DIAGNOSIS: From folder:BIRTH HISTORY SUBSEQUENT HISTORY MEDICATION – type and what it is for SURGERY – date and type

 

Subjective - interview21

SUBJECTIVE ASSESSMENT   Impairments (only describe impairments relevant to the individual

child)Mental functionSight, hearingSpeechFeedingPainRespiratory or cardiac functionContinenceSkin condition

Subjective - interview22

Activities Learning and applying knowledge Communication Self-care; dressing, bathing, brushing teeth Physical activity (highest level of activity, duration or distance?)

Participation Domestic life (how he spends his day?) Interpersonal relationships Schooling, education Community and social life Environment Appliances Transport Accessibility in home (type of house, no. of rooms, no. of people sleeping per room, available

amenities, space move around) and other areas Support of community and family involvement Services (disability and child support grant)

Objective assessment23

Start with activities;What is highest level of function? Work down. In each position, observe posture and

quality of movement.Use objective measures such as the AIMS or the Gross Motor Function Measure

Then examine Impairments as applicableMental functionSight, hearingSpeechFeedingPainRespiratory or cardiac functionContinenceSkin condition

TONEDescribe tone in all affected muscle groups. ROMIf full range of motion, document FROM.If range is limited, you must measure limitation with goniometer and record accurately.

 MUSCLE LENGTH AND STRENGTH :Note when muscle is shortened or weak

Use of the ICF Framework24

This should be used: To analyse the relationships between the different

components so that, main problems can be identified and underlying causes

can be treated.

Steps25

Once the data has been gathered, the thinking begins!

Questions: What are the patient’s main problems? (These are usually

activity limitations or participation restrictions, but not always. Pain or productive coughing are examples of impairments that could be the main problems)

What are the underlying causes of these problems? (These are usually impairments, e.g. weak muscles, soft tissue damage, pain in the knee on walking)

How can change in either impairments or activity limitations be measured?

26Use of ICF Framework

Health Condition (disorder/disease)

Environmental Factors

Personal Factors

Body function&structure (Impairment)

Activities(Limitation)

Participation(Restriction)

Based on: World Health Organisation (WHO), 2001. International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: http://www.disabilitaincifre.it/documenti/ICF_18.pdf

Example use of conceptual framework

Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibited. From: Physical Therapy, Volume 86, Number 9, September 2006. A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

Example of the conceptual framework

Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibited. From: Physical Therapy, Volume 86, Number 9, September 2006. A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

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ExampleHEALTH CONDITION

Fractured tib/femur - acute. Car accident.External fixation

IMPAIRMENTS ACTIVITY LIMITATION PARTICIPATION RESTRICTION

Pain in thighSoft tissue damage

Bed rest Unable to look after infant at home

Weak muscles – upper limbs quads and gluts Cannot bridge to use bed pan Lost domestic work job due to accident

Limited RoM of knee Cannot shift in bed

Swelling Cannot reach locker

Sore under heel Cannot come into sitting

Productive cough No balance in standing

Anxious

ENVIRONMENTAL FACTORS PERSONAL FACTORS

Locker not close to bed No husband

Overweight

Supportive mother Depressed

Ward has no parallel bars Smoker

Home - one story and accessible to wheelchair and crutch walking

Not yet applied to Road Accident Fund for compensation

Finally! Integrate all the data30

PROBLEM LISTDocument FUNCTIONAL problemsPrioritise the most important problems and analyse completely, using the following table.  FUNCTIONAL MISSING UNDERLYING INTERVENTION INDICATOR PROBLEMS COMPONENTS REASONS Usually Usually Usuallyactivity or activity impairmentparticipationrestriction  SHORT TERM AIMSMust be functional aims (likely to be achieved in the next few treatment sessions)  LONG TERM AIMThink of ONE function you would like to improve in 6 months time. SOAP NOTESIncludes daily updates on the Subjective, Objective, Analysis of Problems and treatment plan.

Image references

Rehab-CYCLE. Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibited.

Interaction of Concepts ICF 2001. Based on: World Health Organisation (WHO), 2001. International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: http://www.disabilitaincifre.it/documenti/ICF_18.pdf

“A Senior Chief performs a lift” by Official U.S. Navy Imagery CC-BY-2.0 http://www.flickr.com/photos/usnavy/7879791142/

“Human Skeleton 4” by BarbieDePlastico CC-BY-NC-ND-3.0 http://barbiedeplastico.deviantart.com/art/Human-skeleton-4-151850064

“Ciao Zio” by narice28 CC-BY-NC-SA-2.0 http://www.flickr.com/photos/49379577@N00/2200844241/

“Soccer 20100525” by George Brett (ghbrett) CC-BY-NC-SA-2.0 http://www.flickr.com/photos/orpost/4646511748/

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Image references

“Mobile Ejector Seat” by Arty Smokes CC-BY-NC-SA-2.0 http://www.flickr.com/photos/artysmokes/3525325848/

"Richard Dawkins and Spock" by ssoosay CC-BY-2.0 http://www.flickr.com/photos/76284765@N00/5152049387/

Use of ICF Framework. Based on: World Health Organisation (WHO), 2001. International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: http://www.disabilitaincifre.it/documenti/ICF_18.pdf

Example use of conceptual framework. Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibited. From Physical Therapy, Volume 86, Number 9, September 2006. A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

Example use of conceptual framework. Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational purposes, research purposes, or personal use. Commercial use is prohibited. From Physical Therapy, Volume 86, Number 9, September 2006. A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

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Introduction in the use of the International Classification of Functioning (ICF) in clinical management in undergraduate physiotherapy programme.

by Prof. Jennifer Jelsma, Physiotherapy Division, School of Health and Rehabilitation Sciences, University of Cape Town

is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 2.5

South Africa License. Please see http://creativecommons.org/licenses/by-nc-sa/2.5/za/ for terms and conditions. All images created by external parties retain their original

licenses (see Image references).

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The End

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