The International Classification of Functioning, Disability and Health (ICF)--application to physiotherapy.

"The limits of my language mean the limits of my world." Ludwig Wittgenstein (1889-1951)

For many decades now sociolinguists and social psychologists have been describing the way language can influence action. The words we use can structure the way we think, the decisions we make, and actions we take. In physiotherapy therefore, the language we use to talk about pathology, injury, illness and disability can influence our clinical decisions and the way we interact with our patients and other health professionals.

In 1980 the World Health Organisation published the International Classification of Impairment, Disability and Handicaps (ICIDH), which provided health professions with a common language to describe and better understand processes of disability and rehabilitation. So significant was this new language that Wade and Halligan (2003) recently described it as "perhaps one of the greatest advances in rehabilitation in the last 20 years" (p 349). The ICIDH has now been superseded by the International Classification of Functioning, Disability and Health (ICF), which was endorsed by the World Health Assembly in May 2001. It is beneficial for physiotherapists to have knowledge of how this classification system is structured and how it might be applied to the clinical environment.

What is the ICF?

There are two aspects to the ICF worth discussing here. Firstly, it is a conceptual framework that describes disability, functioning and consequences of health conditions. Secondly, it is a system of classification of the ways disability (and abilities) can manifest through activities and social roles as well as through biology, physiology and psychology. The ICF is not an assessment or measurement tool itself, but is a framework that can be applied to rehabilitation, government policy, disability services, or to assessment, outcome measurement and research.

The ICF presents functioning and disability as multi-dimensional concepts, which relate to: a) body structures and body functions including physiological and psychological function, b) the activities and people do, and c) the life situation and social roles that people participate in. All these aspects of functioning can be directly or indirectly affected by health conditions, illness disorders, or disease processes, resulting in impairments, activity limitations, and/or participation restrictions. The ICF provides specific definitions for each of these as follows:

"Impairments" are problems in body function or structure, such as a significant deviation or loss (e.g. raised blood pressure, pain, or cognitive deficits). "Activity limitations" are defined as difficulties that an individual may have executing activities (e.g. inability to walk, dress oneself, or hang out washing). "Participation restrictions" are the problems that an individual may experience with involvement in life situations (e.g. inability to return to work, or inability to fulfil one's normal social roles in a family).

However, the ICF also describes how functioning and disability can be influenced by environmental factors (such as the physical environment, physical aids and appliances, social policies, or even other people attitudes and beliefs) and by personal factors (such as one's ethnicity, gender, and personality characteristics). In this way, the ICF introduces sociocultural dimensions as well as biomedical ones into the language of disability and functioning. The interrelationships between all these factors and concepts are represented in Figure 1.

[FIGURE 1 OMITTED]

As mentioned, there is a more detailed classification system associated with this conceptual framework. Essentially this classification system is derived from a hierarchy of headings and subheadings, starting from the elements described in the conceptual framework above. Like the International Statistical Classification of Disease and Related Health Problems (ICD-10), the ICF uses an alphanumeric system to classify items relating to functioning and disability. For example, the code "d4103" is used to classify difficulties with getting into and out of a seated position from lying. Modifiers can also be added to indicate the extent or magnitude of disabilities. For instance, a severe (but not complete) activity limitation related to getting from lying to sitting is represented by "d4103.3"

Application of the ICF

The ICF has many uses. One specific use relates to the process of rehabilitation planning. Patient assessment can be conducted using the ICF conceptual framework to better understand the genesis of the patient's problems from a holistic perspective. Sociocultural as well as biomedical factors and the relationships between them can be explored when evaluating causes of problems, and therefore these factors can be considered when developing intervention strategies. For physiotherapists working in interdisciplinary teams, the common language provide by the ICF can be used to enhance communication and encourage collaboration between health professionals when planning patient goals or discussing rehabilitation problems. At the New Zealand Rehabilitation Conference held in Dunedin last year, a number of presenters described exactly this (Reardon and Harmon, 2003, and George and Ronaldson, 2003).

When using the ICF in this manner, it is perfectly justifiable to use the ICF definitions and conceptual framework without specific reference to the alphanumeric coding system (AIHW, 2003). In fact, while Wade and Halligan (2002) are extremely supportive of a conceptual framework describing the manifestations of functioning and disability, they question the validity of a universal descriptive classification system, and state that they themselves are not interested in this aspect of the ICF in their clinical work. Alternatively however, Steiner et al (2002), believe that the coding system contributes further to ensuring interdisciplinary team members have a common language to discuss rehabilitation case scenarios. In their use of the ICF for the development of a clinical planning tool, the "Rehabilitation Problem-Solving Form", Steiner et al (2002) strongly encourage reference to the alphanumeric coding system to "ensure consistency in the use of terminology across disciplines" (p 1104). From a practical perspective however, one would need to consider the time and cost associated with training and supporting staff in the use of the coding system.

Of course the ICF is not just limited to interdisciplinary rehabilitation services. It can also be useful for the individual clinician working in a small practice or in other specialised areas of physiotherapy. For instance, the ICF can provide an assessment structure that moves focus away from pathology when working with people who have chronic pain syndromes or acute low back pain with "yellow flags". It can also be useful for conceptualising and prioritising a treatment plan for people who have other complex presentations, such as multiple injuries or challenging sociocultural backgrounds. Whatever the clinical work, the ICF encourages practitioners to move away from treating problems and towards treating people.

Websites for further information

For further information on the ICF, two excellent websites are:

* The World Health Organisation's website for the ICF: http://www3.who.int/icf/icftemplate.cfm

* The website for Australian Collaborating Centre for the WHO Family of International Classifications, which produces the Australian ICF User's Guide: http://www.aihw.gov.au/ disability/icf/index.html

References

AIHW (Australian Collaborating Centre for the WHO Family of International Classifications). ICF Australian User Guide (Version 1). Canberra: AIHW.

George, J., and Ronaldson, A. (2003) Integrating the ICF into rehab practice--a work in progress. New Zealand Rehabilitation Conference (Conference Programme and Abstracts): pp 20.

Reardon, F., and Harmon, J. (2003) The seven minute challenge: The reality of MDT goal setting. New Zealand Rehabilitation Conference (Conference Programme and Abstracts): pp 16.

Steiner, W. A., Ryser, L., Huber, E., Uebelhart, D. Aeschlimann, A., and Stucki, G. 2002. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Physical Therapy. 82(11): 1098-1107.

Wade D, and Halligan P. (2003) New wine in old bottles: the WHO ICF as an explanatory model of human behaviour. Clinical Rehabilitation. 17(4): 349-354.

WHO (World Health Organization). (1980). International Classification of Impairment, Disability, and Handicap. Geneva: WHO.

WHO (World Health Organization). (1992). International Statistical Classification of Diseases and Related Health Problems, 1989 Revision. Geneva: WHO.

WHO (World Health Organization). (2001) International Classification of Functioning, Disability and Health. Geneva: WHO.

ADDRESS FOR CORRESPONDENCE

William Levack BPhty, MHealSc(Rehabilitation), Lecturer in Rehabilitation, Rehabilitation Teaching and Research Unit, Wellington School of Medicine, PO Box 7343, Wellington South, New Zealand. Email: [e-mail]