ICF and Application in Clinical Practice

Original Editor - Ewa Jaraczewska based on the course by Patricia Saleeby

Top Contributors - Ewa Jaraczewska, Jess Bell and Tarina van der Stockt  

Introduction

The comprehensive and holistic nature of the International Classification of Functioning, Disability and Health (ICF) makes it extremely useful in clinical practice. The primary purpose of applying the ICF into clinical practice is to establish a common language for defining health and health-related states between different providers. It improves communication in decision making among healthcare and social care professionals, which is essential for making more informed assessments, developing more effective interventions, and achieving good patient outcomes.

Overview of ICF

The ICF defines the interaction between health conditions, personal and social factors, daily activities, and social life.The relationship between these various domains and components is reciprocal, which explains how they interact with one another.

The following are the characteristics of the ICF:

• The ICF is universal: it applies to all people regardless of age, gender, socioeconomic and health condition.

• The ICF is neutral: it does not relate a person's functioning to the cause of their health status.
• The ICF uses neutral language when describing health and health-related states.
• The ICF provides a continuum between functioning and disability.

Framework

The ICF is a biopsychosocial model of functioning, health and disability. Using standard language to define and measure disability, the ICF helps explain how a person's body problems and social circumstances affect a person's functioning.

Definitions for the ICF Domains/Components

Based on the ICF model, the person is viewed in terms of their health conditions, body functions and structures, activities and participation, and environmental and personal factors.

• Health condition: "an umbrella term for disease, disorder, injury, trauma"
• Body Functions:" physiological functions of body system, including psychological functions"
• Body Structures: "anatomical parts of the body, such as organ, limbs and their components"
• Activity: "execution of a task or action by an individual". Activity limitations describes the problems or issues at the level of the individual.
• Participation: "involvement in a life situation". Participation restrictions are problems the individuals may experience in their life situation or within environmental context.
• Environmental factors: "physical, social and attitudinal environment in which people live".
• Personal factors: "particular background of an individual's life and living".

You can learn more about ICF components and ICF qualifiers here.

Case Study

Case study: A patient sustained a burn injury to the hand causing damage to the integrity of the skin structure.

Goal:To define ICF codes that correspond to this patient's injury for the purpose of assessmentHealth condition (ICD-11): Burn injury to the hand

• ND95:Burn of wrist or hand
  • ND95.3: Burn of wrist or hand, full thickness burn

Body structure codes (s codes) according to specificity :

• s810: structures of the area of skin
• s8102: skin of the upper extremity

Body functions (b codes) following the skin healing process:

• b810: protective functions of the skin may be impaired temporarily
• b820: functions of the skin for repairing breaks and other damage to the skin (from wound stage to scar formation)
  • Inclusion and exclusion criteria can be applied to the body functions domain:
    • Inclusion: function of scab formation, healing, scaring; bruising and keloid formation
    • Exclusion: the skin's protective function and other skin functions.

Activities and Participation (d codes) can be restricted due to nerve damage or poor healing, which can affect long-term mobility and hand function, including:

• d445: hand and arm use
• d440: fine use of the hand
  • d4401:use one or both hands to seize or hold something (example: grasping a tool or a door knob)
• d550: eating (example: "carrying out the coordinated tasks and actions of eating food that has been served, bringing it to the mouth and consuming it in culturally accepted ways, cutting or breaking food into pieces, opening bottles and cans, using eating implements, having meals, feasting, or dining".)
• d750: limited or lack of informal social relationships, including meeting with a neighbour or participation in happy hour with co-workers due to cosmetic concerns and body image distress.
• d845: not being able to maintain the job due to anxiety and perceived stigma related to scarring in the hand area.

Environment(e codes)

• e460: not comfortable going out shopping due to societal attitude towards visible scars, causing person's anxiety

Core Sets

ICF Core Sets (ICF­CS) are a " selection of essential categories from the full ICF classification that are considered most relevant to describe the functioning of a person with a specific health condition or in a specific healthcare context". Their purpose is to facilitate assessments in clinical practices and research.

The ICF Core Sets are shortlisted from over 1400 ICF categories describing functioning, disability and health. They are developed for acute, early post-acute and long-term conditions, but they are also categorised as neurological, musculoskeletal, cardiopulmonary conditions, spinal cord injury and vocational rehabilitation. Each ICFCS has its comprehensive and brief versions. Brief version of ICFCS contains categories, that describe functioning at its minimum standard.

The process of the ICF Core Set creation is complex and includes three phases:

• Phase 1: Collecting the evidence that contains an empirical multi-centre study, a systematic literature review, a qualitative study and an expert survey who are only health professionals who practise with clients but also the clients with a specific health condition
• Phase 2: The international consensus conference
• Phase 3: Implementation of ICF­CSs by introducing them into practice

The purposes of using the ICF Core Sets in clinical practice can be as follows:

• to help with selecting an appropriate combination of outcome measures
• to assist with selecting a tool in developing comprehensive outcome measures
• to describe patterns of disability [41].
• to inform about the magnitude, the location and the nature of any functioning problem.
• to highlight strengths and weaknesses of an individual patient
• to describe changes in a patient’s functional profiles over time.

Clinical Forms

The development of clinical forms allows health care professionals to focus on specific patient problems and " relate the disabilities to relevant and modifiable variables." The following is the summary by Levesque L and Thoomes E of the use of clinical forms in clinical practice:

• It encourages a biopsychosocial perspective
• It allows the clinician to identify all factors within the ICF model
• It directs the healthcare professionals to use the most appropriate objective tests and outcome measures
• It  highlights contextual factors – personal and environmental which may affect prognosis and patients' recovery
• It enables the clinician to identify factors which can be modifiable.

Rehabilitation Problem-Solving Form (RPS-Form)

The Rehabilitation Problem-Solving Form (RPS-Form) facilitates the patient's assessment by various healthcare professionals by addressing all components of human functioning and environmental and personal factors. Additionally, the RPS-Form incorporates patients' perspectives and enhances their participation in the decision-making process of rehabilitation. It is a tool in clinical use ,which collects information from the ICF to enhance the patient-centred approach and the decision- making process. The form contains areas designated for the ICF domains, categories, and codes.

This form can:

• help identify target problems and factors that contribute to these problems.
• identify a plan that is most appropriate in terms of the treatments and interventions that are needed for a particular patient
• facilitate interprofessional communication
• help to indicate or record information and the views of the client and patient, as well as information coming from professionals, or across clinicians.
• help to improve the communication between the health professionals and their clients by recording the views presented by a patient and a provider

You can find more about the application of the RPS form for a specific condition here.

Physical Therapy Clinical Reasoning and Reflection Tool (PTCRT)

Clinical reasoning is described as a core skill needed for solving clinical problems and for establishing rapport with patients. It allows the healthcare providers, including physiotherapists, to integrate the patient's needs and experiences with their reasoning and decision-making in practice.

The Physical Therapy Clinical Reasoning and Reflection Tool (PTCRT) uses the ICF framework to guide the physical therapists' practice and facilitate clinical reflection, and improve clinical decision-making. The success of the clinical reasoning process can be measured by achieving favourable outcomes in a collaboration with the patient. This form has designated areas aligned with the ICF domain, which allows the clinician to record relevant categories and codes when working with a patient. The environmental section of this tool includes internal and external environmental factors which can become barriers and facilitators. The barriers are indicated by a minus sign and the facilitators by a positive sign.

Sections of the Physical Therapy Clinical Reasoning and Reflection Tool (PTCRT) can be used to guide critical thinking, or the physiotherapist can complete the entire worksheet to "identify further potential inquiries to explore, either by a review of the evidence or by designing a new and important clinical question".

You can find The Physical Therapy Clinical Reasoning and Reflection Tool (PT-CRT) here.

Cross-Walking of the ICF

A number of clinical professional associations have integrated the ICF into their respective scope of practice. One of the methods to include the ICF categories in the rehabilitation practice is a cross-walking of the ICF to existing clinical instruments. In the study by Pongpipatpaiboon K et al. it was found that less than 50% of the ICF categories were present in the clinical assessment tools for individuals with a spinal cord injury. This phenomenon was observed especially in the acute and late long-term phases of spinal cord injury rehabilitation, where activities and participation and environmental factors were least covered. However, more ICF categories were included in the assessment after they were identified during the patient's interview. The results of this study highlighted the underrepresentation of the environmental factors across the spinal cord injury continuum of care.

The cross-walking has specific linking rules developed by a group of individuals involved in the WHO development and maintenance activities. The main rule is described in work by Cieza et al. and states the following: "Before one links meaningful concepts to the ICF categories, one should have acquired a good knowledge of the conceptual and taxonomical fundaments of the ICF, as well as of the chapters, domains, and categories of the detailed classification, including definitions".

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