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How do we decide what to do with our patients?

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1 How do we decide what to do with our patients?
Introduction in the use of the International Classification of Functioning (ICF) in clinical management in undergraduate physiotherapy programme. JENNIFER JELSMA UNIVERSITY OF CAPE TOWN

2 Introduction 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.

3 The process 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. 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 Steiner 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:

4 The Problem A useful manner to gather the information gained during the patient assessment is to use the ICF 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? Problem 1: There is so much information that must be gathered some of it is not important and some ends up by being essential.

5 Objective of the module
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.

6 The ICF Official classification of WHO
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. 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 on 21/07/11.

7 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.

8 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

9 What causes disability? 1980
Disease or disorder Impairments Disabilities Handicaps

10 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), International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online:

11 ICF Components Body Functions & Structures Activities & Participation
Environmental Factors Functions Structures Capacity Performance Barriers Facilitators “A Senior Chief performs a lift” by Official U.S. Navy Imagery CC-BY-2.0 “Human Skeleton 4” by BarbieDePlastico CC-BY-NC-ND-3.0 “Ciao Zio” by narice28 CC-BY-NC-SA-2.0 “Soccer ” by George Brett (ghbrett) CC-BY-NC-SA-2.0 “Mobile Ejector Seat” by Arty Smokes CC-BY-NC-SA-2.0

12 Body Functions and Structures
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

13

14 Body Structures S240 Structure of external ear

15 S240 Structure of external ear
s7302 Structure of hand

16 Activities and Participation
1 Learning &Applying Knowledge 2 General Tasks and Demands 3 Communication 4 Movement 5 Self Care 6 Domestic Life Areas 7 Interpersonal Interactions 8 Major Life Areas 9 Community, Social & Civic Life

17 Environmental Factors
1. Products and technology 2. Natural environment and human-made changes to the environment 3. Support and relationships 4. Attitudes 5. Services, systems and policies

18 How does the ICF assist in clinical reasoning ?
Can assist In identifying what is the most important area to concentrate intervention for the patient on that day It can assist in analysing the relationships between the 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 Decision Making Analysis Data Gathering

19 Application of the ICF in the clinical setting

20 Assessment of children with neurological problems
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

21 Subjective - interview
SUBJECTIVE ASSESSMENT Impairments (only describe impairments relevant to the individual child) Mental function Sight, hearing Speech Feeding Pain Respiratory or cardiac function Continence Skin condition

22 Subjective - interview
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)

23 Objective assessment 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 applicable Mental function Sight, hearing Speech Feeding Pain Respiratory or cardiac function Continence Skin condition TONE Describe tone in all affected muscle groups. ROM If 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

24 Use of the ICF Framework
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.

25 Steps 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?

26 Use 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), International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online:

27 Example use of conceptual framework
Context: This slide presents the relationships among components of health & contextual factors for Teresa at 17 months of age. Her health condition is preterm birth - hypertonia The red lines indicate relationships that are considered most importance The relationship between impairments in body functions & structures AND activity limitations is emphasized. 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 A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

28 Example of the conceptual framework
Context: At 10 years of age, note the issue that has emerged. The direction of the top red arrows indicate that activity limitations are thought to contribute to secondary impairment Increased environmental demands & personal factors are proposed to be important in addressing concerns regarding participation A recommendation for intervention is an exercise & fitness program that does not involve high impact forces. Small group is recommended as the method of service delivery 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 A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

29 Example HEALTH CONDITION
Fractured tib/femur - acute. Car accident.External fixation IMPAIRMENTS ACTIVITY LIMITATION PARTICIPATION RESTRICTION Pain in thigh Soft 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

30 Finally! Integrate all the data
PROBLEM LIST Document FUNCTIONAL problems Prioritise the most important problems and analyse completely, using the following table. FUNCTIONAL MISSING UNDERLYING INTERVENTION INDICATOR PROBLEMS COMPONENTS REASONS Usually Usually Usually activity or activity impairment participation restriction SHORT TERM AIMS Must be functional aims (likely to be achieved in the next few treatment sessions) LONG TERM AIM Think of ONE function you would like to improve in 6 months time. SOAP NOTES Includes daily updates on the Subjective, Objective, Analysis of Problems and treatment plan.

31 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 Based on: World Health Organisation (WHO), International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: “A Senior Chief performs a lift” by Official U.S. Navy Imagery CC-BY-2.0 “Human Skeleton 4” by BarbieDePlastico CC-BY-NC-ND-3.0 “Ciao Zio” by narice28 CC-BY-NC-SA-2.0 “Soccer ” by George Brett (ghbrett) CC-BY-NC-SA-2.0

32 Image references “Mobile Ejector Seat” by Arty Smokes CC-BY-NC-SA-2.0 "Richard Dawkins and Spock" by ssoosay CC-BY-2.0 Use of ICF Framework. Based on: World Health Organisation (WHO), International Classification of Functioning, Disability and Health, Geneva, pg 18. Accessed online: 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 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 A collaborative model of service delivery for children with movement disorders: a framework for evidence-based decision making, by RJ Palisano.

33 Creative commons license
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 for terms and conditions. All images created by external parties retain their original licenses (see Image references). Source work available at vula.uct.ac.za Permissions beyond the scope of this license may be available at or

34 The End


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