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ICF and Application in Clinical
Practice
Introduction
The comprehensive and holistic nature of the International
Classification of Functioning, Disability and Health (ICF) makes it
extremely useful in clinical practice. [1] The primary purpose of
applying the ICF in clinical practice is to establish a common
language for defining health and health-related states between
providers.[2] It can enhance decision-making among healthcare
and social care professionals. The ICF's holistic approach is
essential for making more informed assessments, developing
more effective interventions, and achieving good patient
outcomes.[1]
Overview of ICF
The ICF defines the interaction between health conditions,
personal and social factors, daily activities, and social life. [3] The
relationship between these various domains and components is
reciprocal, which explains how they interact by mutually
influencing one another. [1]
The following are characteristics of the ICF: [4]
The ICF is universal: it applies to all people regardless of
age, gender, socioeconomic status 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 to explain how a person's body problems
and social circumstances affect their functioning.
Definitions for the ICF Domains/Components
ICF Biopsychosocial Model
In the ICF model, a person is viewed in terms of their health
conditions, body functions and structures, activities and
participation, and environmental and personal factors. [1]
Health Condition: "an umbrella term for the disease,
disorder, injury, trauma" [4]
Body Functions: "physiological functions of the body
system, including psychological functions" [4]
Body Structures: "anatomical parts of the body, such as
organ, limbs and their components" [4]
Activity: "execution of a task or action by an individual".
[4]
Activity limitations describe the problems or issues at the
level of the individual. [1]
Participation: "involvement in a life situation".
[4]
Participation restrictions are problems the individual may
experience in their life situation or within an environmental
context.[1]
Environmental Factors: the "physical, social and attitudinal
environment in which people live". [4]
Personal Factors: the "particular background of an
individual's life and living". [4]
You can learn more about the ICF components and ICF
qualifiers here.
Types of Burn
Case Study
Case study: A patient sustained a third degree burn injury to the
hand causing damage to the integrity of the skin structure. [1]
Goal: To define ICF codes that correspond to this patient's injury
for the purpose of assessment
Health condition (ICD-11): Burn injury to the hand
ND95: Burn of wrist or hand
o 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)
o The body functions domain can include inclusion and
exclusion criteria:
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
o 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 participating in
happy hour with co-workers due to cosmetic concerns and
body image distress
d845: inability to maintain a 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, which causes anxiety
ICF 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" [5] Their purpose is to
facilitate assessment in clinical practice and research. [6]
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. They are
also categorised as neurological, musculoskeletal,
cardiopulmonary conditions, spinal cord injury and vocational
rehabilitation. [5] Each ICFCS has comprehensive and brief
versions. The brief version of an ICFCS contains categories that
describe functioning at its minimum standard. [5]
The process of ICF Core Set creation is complex and includes
three phases: [5]
Phase 1: Collecting evidence that contains an empirical
multi-centre study, a systematic literature review, a
qualitative study and an expert survey. Expert surveys
capture the perspective of health professionals who work
with patients with a specific health condition. [1]
Phase 2: There is an international consensus conference
where experts and health professionals look at the
"candidate" ICF categories and decide which ICF categories
should be included in the ICFCS.
Phase 3: The ICFCS is implemented and introduced into
practice.
Using the ICF Core Sets in clinical practice has several purposes,
including:[7]
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.
To inform about the magnitude, the location and the nature
of any functioning problem.
To highlight the 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 professionals to
focus on specific patient problems and "relate the disabilities to
relevant and modifiable variables." [8] The following is the
summary by Levesque and Thoomes of the advantages of using
clinical forms in practice: [9]
They encourage a biopsychosocial perspective.
They allow the clinician to identify all factors within the ICF
model.
They direct the healthcare professional to use the most
appropriate objective tests and outcome measures.
They highlight contextual factors – personal and
environmental which may affect prognosis and a patient's
recovery
They enable the clinician to identify factors which can be
modifiable.
Rehabilitation Problem-Solving Form (RPS-
Form)
The Rehabilitation Problem-Solving Form (RPS-Form) facilitates
the assessment of a patient by various health professionals as it
addresses 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. [10] It
is a tool in clinical practice, [8] which collects information from the
ICF to enhance the patient-centred approach and the decision-
making process. The RPS-Form contains areas designated for the
ICF domains, categories, and codes.
This form can: [1]
Help identify target problems and factors that contribute to
these problems.
Identify the most appropriate plan in terms of the
treatments and interventions needed for a particular
patient.
Facilitate interprofessional communication.
Help to provide information, including the views of the
patient, professionals, clinicians.
Help to improve communication between health
professionals and their clients by recording their views.
You can find out more about the application of the RPS form for a
specific condition here.
Physical Therapy Clinical Reasoning and
Reflection Tool (PTCRT)
Clinical reasoning is a core skill needed for solving clinical
problems and establishing rapport with patients. It allows
healthcare providers, including physiotherapists, to integrate the
patient's needs and experiences with their reasoning and
decision-making in practice. [11]
The Physical Therapy Clinical Reasoning and Reflection Tool (PTCRT)
uses the ICF framework to guide a physical therapist's practice
and facilitate clinical reflection. [1] Achieving favourable outcomes
in collaboration with the patient defines the success of the
clinical reasoning process. [12] This form has designated areas
which are aligned with ICF domains. This 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. [1]
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".[12]
You can find The Physical Therapy Clinical Reasoning and
Reflection Tool (PT-CRT) here.
Cross-Walking of the ICF
Several clinical professional associations have integrated the ICF
into their respective scope of practice. [1] But, perhaps more
commonly in practice, there has been a "cross-walking" of the
ICF to existing clinical instruments. [1] This enables ICF categories
to be included in rehabilitation practice.
Cross-walking has specific linking rules developed by a group of
individuals involved in the WHO development and maintenance
activities. [1] The main rule is described in work by Cieza et al.
[13]
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". [13]
It is worth noting that more work must be done to ensure the ICF
is incorporated into practice. A study by Pongpipatpaiboon et al.
[14]
found that less than 50% of the ICF categories were present in
the clinical assessment tools for individuals with a spinal cord
injury.[14] This phenomenon was observed primarily in the acute
and late long-term phases of spinal cord injury rehabilitation.
Activities, participation, and environmental factors were the least
covered in these phases. However, more ICF categories were
included in the assessment after the patient's interview identified
them.[14] The results of this study highlighted the
underrepresentation of the environmental factors across the
spinal cord injury continuum of care. [1
