ICF Model and Goal Writing in Paediatrics

ICF

ICF which stands for the International Classification of Functioning, Disability and Health is a World Health Organization classification of health and health-related arenas. This framework measures health and disability at both the individual and population levels while also looking at environmental factors.This framework emphasises function, impact and health rather than disability and cause. (jia)

The aim of Physical Therapy Diagnosis (PTD) or Functional Diagnosis (FD) is to diagnose movement system impairments to guide intervention for health optimization such that the disability can be minimized.[4,5,6,9,10] The objective is clearly focused in the expertise of identifying clusters of movement system dysfunction and classifying them rather than diseases.[6,10] Treatment effectiveness and prognosis are further mapped for a particular classification of movement system impairment using function as an outcome. This not only increases effectiveness of practice but also contributes to health care and research.[3,6,9,10] (jian)

The key diagnostic questions addressed are: (1) what are the impairments, their nature and source? (2) Which impairments are related to patients functional limitation? (3) Which amongst these can be remedied by intervention? (4) What is the influence of the contextual (environment and personal) factor of a person in his function? (5) Can the contextual factors be changed or remedied to maximize performance? (6) What is the diagnostic label?The focus of physical therapist is differential evaluation and the treatment of dysfunction rather than differential diagnosis and treatment of disease as in the case of physician.[1

Where a medical diagnosis is important for defining the cause and prognostication, a physical therapy diagnosis is important to identify the limitations of function and quality of life within the given context of the individual to guide physiotherapy interventions

TD is the result of a process of clinical reasoning using a problem-oriented hypothetico-deductive model.[13,14] Potential impairments present primarily or secondarily as a consequence of tissue pathology are identified along with the need for health restoration and prevention.[11,14] A detailed patient interview that includes information about the limitation of function in activities of daily living leads to the pattern recognition of movement dysfunction and generation of hypothesis stating which body structures and functions may be impaired.[13] A brief examination that includes review of systems, communication ability, coping style, language, learning style, and “red flags” is conducted. From the above, the therapist concludes the need to carry out specific tests and measures to investigate the generated diagnostic hypothesis or refer to another practitioner. The link between impairments, activity limitation, and participation restriction is identified. The relationship between the individual's health condition and contextual factors influencing the individual is explored to find the cause of the resultant disability.[9] The data thus obtained would guide for intervention strategies, plan of care, prognosis, and scope of practice.(

Body charts reveal extent of distress associated with pain. Structured interviews are used to assess: (i) physical environment at workplace, home settings, school or college, and workplace; (ii) level of anxiety, fear, depressed mood, perceived workplace problems (job satisfaction/stress, work satisfaction), and family support. Fear avoidance, self-efficacy, and coping strategies are evaluated using questionnaires. Functional assessment scales are used to assess components of function. For instance, functional independent measures assess the level of dependency in activities of daily living, and the disease-specific and generic quality of life scale measures the individual at physical, emotional, and social levels.

WHO-ICF is a framework for organizing and documenting information on functioning and disability (WHO 2001). It conceptualizes functioning as a “dynamic interaction between a person's health condition, environment factors and personal factors,” thus giving a holistic understanding of health. ICF integrates both a medical model and a social model as “bio-psycho-social synthesis” and does not focus on one's disease, illness, or disability alone

Information within ICF is organized in two parts, one dealing with “Functioning and Disability” and other with “Contextual factors”.[15,16] This assists the physiotherapist to assess and understand each person's experience of functioning and disablement in relation to their living conditions. A complex, dynamic, and unpredictable relationship of various domains of ICF exists, which is bidirectional. The framework assists in goal setting, evaluation of outcomes, and communication among colleagues or people using a common language.[14,20] Patient management for a health condition can be planned more effectively when one understands how functioning is affected due to health condition (ICD) of the individual in context (situation) to which he or she functions (ICF

he identification of secondary impairments as a consequence of primary helps in planning of preventing strategies. In circumstances where direct physical therapy treatment cannot remediate impairments, the framework allows to plan modification in functions.

The degree of functional limitation is assessed on the basis of ability to execute a task or action (activity) and capacity to fulfill socially defined roles (participation). These roles are expected of an individual in terms of work, family, peers, etc. within a sociocultural and physical environment.[14,15] Hence, the framework concentrates not only on the individual but also the immediate and distant factors that may affect functioning positively or negatively

The domain of “environment and personal factors” evaluates the bio-behavioral constructs that may facilitate or hinder overall functioning with respect to physical, social, and attitudinal world.[15] Setting at work, home, or school, motivation level of the individual, degree of family support, and factors related to perceived problems within the environment (psycho social) are evaluated to plan ergonomic modification, prescription of assistive devices, and therapy to improve performance in the given situation.

Personal factors are the particular background of an individual's life and comprise features of an individual that are not part of a health condition or health states but have an effect on disability and functioning.[15] Factors most relevant to physiotherapist are gender, age, lifestyle, fitness, habits, profession, coping styles, culture, beliefs and ideologies, and attitudes such as pain experience, fear avoidance, and self-efficacy.(jian)

Jiandani MP, Mhatre BS. Physical therapy diagnosis: How is it different?. Journal of postgraduate medicine. 2018 Apr;64(2):69.So we're talking about not only their impairments and potential medical diagnosis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5954814/

Rast FM, Labruyère R. ICF mobility and self‐care goals of children in inpatient rehabilitation. Developmental Medicine & Child Neurology. 2020 Apr;62(4):483-8. https://onlinelibrary.wiley.com/doi/full/10.1111/dmcn.144710:53

Houtrow A, Murphy N, Kuo DZ, Apkon S, Brei TJ, Davidson LF, Davis BE, Ellerbeck KA, Hyman SL, Leppert MO, Noritz GH. Prescribing physical, occupational, and speech therapy services for children with disabilities. Pediatrics. 2019 Apr 1;143(4).https://publications.aap.org/pediatrics/article/143/4/e20190285/37233/Prescribing-Physical-Occupational-and-Speech

but we're also looking at a multitude of contextual factors that really have an influence on how that

individual is able to participate in their daily activities or activities that are of importance to them.

So when we talk about this, you can break down the ICF model into three components of health.

So these components of health are going to include the body function, functions and body structures

Always make sure that you really have a good concept of what their participation restrictions are and what their participation goals are. But some important key factors to remember is that not all impairments are going to be able to be modified by you.

So that's something that you're going to want to keep in mind whenever you're looking at what

their impairments are and what sort of effect you might have through your interventions.

And not all impairments necessarily are going to limit their ability to participate in an activity of interest.

So just because maybe he does have decreased force protection, maybe he doesn't care if he's going to do the high jump or the long jump.

So again, always, always, always make sure that you're relating your impairments and activity limitations to participation limitations,

because that's really kind of the golden standard for what's important for us to work on as physiotherapists.

And make sure you find out what's important to that child, to their family,

so that you're creating goals that are something that they actually want to work on,

because a lot of this can be pretty hard for the families and the children to have

carry over for when we're coming up with interventions that are appropriat

So his ability to participate is really variable based on that environment and some of these different contexts

the things that they want to do, you are the ultimate goal of our interventions.

So when we talk about this ICF model and really breaking down all of this information that we get from our examination and from our evaluation,

when we try to come up with goals for this patient in their family,

we really want to go back to the things that are important to that family and that patient for them to participate,

to have that highest quality of life.

So moving into developing that goal, like we talked about, there's activity and participation goals are going to be key.

So you're going to listen to what the patient and the family have to say for what's important to them.

And then from that, you are going to look at how you can potentially increase their function and how you can improve their

activities and their participation so that they can do these things that they want to do more easily.

So you want to make sure that when you're developing these goals,

you're doing it in collaboration with the family and that a lot of these things that are important to the family are going to be like,

how you do just basic tasks during the day, like changing their clothes, changing their diaper.

You also want to make sure you think about what the strength of that child in that family are.

Maybe they have a really great support system.

nd then you want to also make sure that you're thinking about what you can

actually do as a physiotherapist that's going to assist in achieving that goal.

So how do we come up with all this information?

Well, of course, to fill out an ICF model, to be able to have an idea about what the patient wants to do,

to have an idea about their limitations and their body structures and functions, we have to get that really nice,

thorough history and examination and make sure we have really good tests and measures that are specific for that particular patient population.

We are going to want to identify the different impairments in body structure and function in their participation restrictions.

And we're going to look at, you know, what is the prognosis of this particular patient and what factors are influencing

that prognosis to make sure that we can come up with attainable goals? So for example, let's say that you have a child who has spastic Julija,

And that might be something that is a little bit of a difficult goal to achieve.

So you want to make sure that you're setting realistic goals that are attainable and achievable for that particular patient.

You also want to think about how long it's going to take to achieve that goal. So we're thinking about our goal setting.

We're going to look at how long we think that particular plan of care for that patient

is going to be and identify goals that can be completed within that timeline.

Often when we make goals, we're talking about developing some short term goals and some long term goals, depending on the patient.

The length of those goals can be different. So a lot of times, you know, I'm setting some short term goals that are four and six weeks and time,

and then we're going to do a check in to see how they're doing and then some longer term goals that might be more in the 12 16 weeks time period.

And that's going to change depending on why you're seeing a patient.

So for example, let's say you have a patient with developmental delay.

You're probably going to see them for episodes of care for a longer period of time.

So you might have goals that extend a little longer. Or maybe you have things that you think, Oh yeah, you'll be able to get this pretty quickly.

Or maybe you have a child who has Down syndrome. And we know that it takes them longer to achieve particular gross motor skills.

So your plan of care might extend a little bit longer in those particular cases.

So keep these factors in mind whenever you're thinking about how long it's going to take to achieve a particular kind of goal.

And then always, always, always make sure that it's important to the patient and important to the caregivers.

So when we talk about smart goals, really what we mean is, you know,

making a goal that has a lot of different features to it that are going to allow you to reassess it in a very specific kind of way.

We want these goals to be objective as much as possible so that we know whether or not we achieved that goal.

So the smart goal is really an acronym.

So the smart goal is really an acronym.

And what it stands for is the essence in the smart is we're specific, so we want to make sure our goal is specific.

So we want to make sure that when we're thinking about something that it has,

like all of the components, tell us to say yes, this is the thing we are doing.

So maybe it's that we want Thomas to be able to walk to school.

All right. So where is he going? He's not just walking. Is walking to school.

Where is he walking from? From his house, from grandmother's house or so?

Thomas is going to be able to walk from his house to his school, and maybe we want him to do this three out of five days each week.

All right. So now we know where he's walking and we know how many days a week he's doing it.

Well, how far is it? You know, is it that detour with construction?

So OK, maybe it's one mile. So now Thomas is walking three out of five days a week from his house to his school over one mile distance.

So now we have all of these very specific components of where Thomas is walking.

The next thing that we're going to look for in our goal is that it's measurable. So we have to have some way to give some context to the goal.

So. All right. Maybe he's walking there, but does it count if it takes him three hours to get there?

That probably doesn't make sense, right?

I mean, he can't spend three hour, three hours of his day walking to school and then another three hours of his day walking home from school.

He's going to be too exhausted to know anything that happened during the school day, and he's probably going to miss most of it.

So maybe we want him to be able to do that walk to school three to five days of the week.

That's going to take him. It's going to be over one mile distance, and maybe we want him to be able to do that in 40 minutes.

And we think that's a reasonable amount of time. Family thinks that's reasonable. So, OK, now it's measurable.

It's going to take him 40 minutes to do that particular task.

And the next part of the goal is you want to make sure it's attainable. Can Thomas actually do this?

So you want to make sure that you're thinking about, all right, like, is this something that we're actually going to be able to get him to?

Because if it's not attainable, if it's not achievable, you're not setting a good goal for him.

You know, maybe you've done tested measure and you've done a six minute walk test.

And you know, his endurance completely plummeted. You know, his vitals were through the roof.

He had, you know, a piece or some sort of, you know, rating of,

like how hard he felt like he was working and it was a nine out of 10 with only six minutes of walking.

Do we really think that we're going to get him to be able to go a mile? Maybe not so attainable.

So I want to make sure this is something that he can do. And, you know, like, it has to be realistic.

So, you know, is this something that your goal is both achievable and you think you can do it in a timeframe that's realistic?

So you know you're going to set a plan of care for maybe 16 weeks? Is he going to be able to get there in 16 weeks?

Or maybe it's going to take him being four years older and that, you know,

he's not going to have that detour anymore before it's actually a realistic goal for him to do this.

nd then lastly, you want to make sure you have that time frame. So how long is it going to take for you to achieve this goal?

So in 12 weeks time? Thomas is going to be able to walk from his house to the school three to five days of the week.

it's going to be over a mile distance and he is going to do this in under 40 minutes.

Maybe there are other measurable components you want to do with a piece or some sort of perceived reading of exertion,

scale of a lesson in six out of 10 or,

you know, with a certain type of gait or, you know, with one person there to assist by providing close supervision only.

So you can add in lots of other specific components to that or measurable components to that.

Make sure it's attainable. This is something that, yeah, we totally think he can do this and we think he can do it within like a single plan of care.

At the age he's in with the potential barriers that are in his way, and we think that he can do this in that 12 week period of time.

So when you have all of that together, there is no question as to whether or not he did or did not achieve his goal because you have all of the

components of this goal that are set up really beautifully for you to be able to then objectively say yes or no.

And what do we need to modify as we move forward to make it a little more realistic,

attainable or achievable if we're not seeing the progress that we anticipated to?

So just going through a different patient and this is something that you're going to use for another knowledge check here next,

so you can use this information as a reference.

So now we have Jonathan, who is a 14 year old boy with hemiplegia after a stroke at the age of 10 years old,

so he wound up with spasticity on his right anybody.

So right hand wrist finger flexor gastric solis.

So he's got decreased muscle extensibility, decreased range of motion and his calves, particularly.

He has really poor activation of his dorsal flexors. So he's got this spasticity that's putting his foot down.

t's really tough for him to fight and pull his toes up to get good foot clearance.

Because of that, he actually uses an AFO on that right foot for his community mobility to make sure he can get good toe clearance and of trepang,

often after participating in a full day of school. He is beat.

He is really tired. It takes a lot out of him. And when he goes home, he likes to take his AFO off, sometimes just because he needs a break from it.

And when he's at home, [INAUDIBLE] kind of furniture start from one thing to the next, and he does have a history of falls.

You know, sometimes from that fatigue,

sometimes from its toe catching whenever he's at home and not wearing his AFL family lives in a two storey home.

And there are six steps to get into the house. Mom and dad both work full time jobs.

They're not at home whenever he gets home, and he has three younger siblings.

One of Jonathan's goals is that he really wants to be able to take his three and four siblings to the park across the street.

That's also up a hill from their home.

So this is information you've gathered so far in your examination and evaluation of Jonathan whenever he came into the clinic with mom and dad.

So what we're going to do is a little knowledge track to come up with two smart goals for Jonathan based on the previously provided information.

So I'm just going to pop that back up for you so that you can kind of jot down some notes if you need to before we go into our knowledge check.

And then that'll be it for us talking about the ICF model and goal setting for today.