An Italian experience in the ICF implementation in rehabilitation: Preliminary theoretical and practical considerations

Purpose. The International Classification of Functioning, Disability and Health (ICF) in its complete form cannot be adopted in clinical rehabilitative practice due to its complexity and size. Ongoing international research is aimed at validating and verifying the reliability of simplified instruments derived from the ICF (ICF Core Sets). An Italian multicentre study was recently conducted with these aims. The purpose of this article is to present some qualitative considerations on ICF Core Sets implementation.

Method. A brief schedule purposely built to assess the difficulties encountered by the health professionals who administered the ICF Core Sets were sent them via e-mail. Due to the small size of the sample, a qualitative analysis was performed.

Result. The main difficulties which emerged were: (i) To clearly translate the ICF categories' contents in a language easily understandable especially by patients with low education and concrete cognitive style, (ii) the process of assigning the qualifier to the given category, particularly with the ‘Activity and Participation’ and ‘Environmental factors’ components, and (iii) the influence of evaluators' different professional backgrounds on interview performance.

Conclusion. Since the classification was designed to uniform language and to promote homogeneous ways of evaluation in extremely different healthcare and social contexts, more studies are necessary to improve reliability and to identify the best methods of using the ICF in daily clinical practice.     

Achieving meaningful measurements of ICF concepts

Purpose. This paper reviews the strengths and weaknesses of two different approaches to assessing ICF concepts: coding versus quantitative scales. It illustrates the advantages of an alternative, integrative approach, called functional staging.

Method. A prospective cohort study. A total of 516 subjects in the Rehabilitation Outcome Study.

Results. ICF codes provide a useful approach for classifying easy-to-interpret health-related information on individuals that can be incorporated into administrative records and databases. By minimizing measurement error, quantitative scales are well suited for synthesizing health-related data that can be used to compare the health states of groups of individuals across studies, conditions, and countries as well as to detect clinically meaningful change. A functional staging approach combines the attractive features of ICF coding and quantitative scales to help the user interpret the clinical meaningfulness of summary scores while retaining measurement reliability, validity and precision.

Conclusions. A functional staging approach to assessing ICF concepts holds promise as a useful technique for measuring and interpreting the core concepts in the ICF framework.     

The Geriatric ICF Core Set reflecting health-related problems in community-living older adults aged 75 years and older without dementia: development and validation

Abstract

Purpose: The aim of the present study was to develop a valid Geriatric ICF Core Set reflecting relevant health-related problems of community-living older adults without dementia. Methods: A Delphi study was performed in order to reach consensus (≥70% agreement) on second-level categories from the International Classification of Functioning, Disability and Health (ICF). The Delphi panel comprised 41 older adults, medical and non-medical experts. Content validity of the set was tested in a cross-sectional study including 267 older adults identified as frail or having complex care needs. Results: Consensus was reached for 30 ICF categories in the Delphi study (fourteen Body functions, ten Activities and Participation and six Environmental Factors categories). Content validity of the set was high: the prevalence of all the problems was >10%, except for d530 Toileting. The most frequently reported problems were b710 Mobility of joint functions (70%), b152 Emotional functions (65%) and b455 Exercise tolerance functions (62%). No categories had missing values. Conclusion: The final Geriatric ICF Core Set is a comprehensive and valid set of 29 ICF categories, reflecting the most relevant health-related problems among community-living older adults without dementia. This Core Set may contribute to optimal care provision and support of the older population.

• Implications for Rehabilitation

• The Geriatric ICF Core Set may provide a practical tool for gaining an understanding of the relevant health-related problems of community-living older adults without dementia.

• The Geriatric ICF Core Set may be used in primary care practice as an assessment tool in order to tailor care and support to the needs of older adults.

• The Geriatric ICF Core Set may be suitable for use in multidisciplinary teams in integrated care settings, since it is based on a broad range of problems in functioning.

• Professionals should pay special attention to health problems related to mobility and emotional functioning since these are the most prevalent problems in community-living older adults.

     

ICF Core Set for patients with neurological conditions in early post-acute rehabilitation facilities

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for neurological patients in early post-acute rehabilitation facilities.

Methods: The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.

Results: Seventeen experts selected a total of 116 second-level categories. The largest number of categories was selected from the ICF component Body Functions (54 categories or 47%). Eleven (9%) of the categories were selected from the component Body Structures, 34 (29%) were of the categories from the component Activities and Participation, and 17 (15%) from the component Environmental Factors.

Conclusion: The Post-acute ICF Core Set for neurological patients is a clinical framework to comprehensively assess patients in early post-acute rehabilitation facilities, particularly in an interdisciplinary setting. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.     

Achieving meaningful measurements of ICF concepts

PURPOSE: This paper reviews the strengths and weaknesses of two different approaches to assessing ICF concepts: coding versus quantitative scales. It illustrates the advantages of an alternative, integrative approach, called functional staging. METHOD: A prospective cohort study. A total of 516 subjects in the Rehabilitation Outcome Study. RESULTS: ICF codes provide a useful approach for classifying easy-to-interpret health-related information on individuals that can be incorporated into administrative records and databases. By minimizing measurement error, quantitative scales are well suited for synthesizing health-related data that can be used to compare the health states of groups of individuals across studies, conditions, and countries as well as to detect clinically meaningful change. A functional staging approach combines the attractive features of ICF coding and quantitative scales to help the user interpret the clinical meaningfulness of summary scores while retaining measurement reliability, validity and precision. CONCLUSIONS: A functional staging approach to assessing ICF concepts holds promise as a useful technique for measuring and interpreting the core concepts in the ICF framework.     

ICF Core Sets development for the acute hospital and early post-acute rehabilitation facilities

The goal of this paper is to report on the background and the methods used in the ICF Core Set development for patients in the acute hospital and early post-acute rehabilitation facilities. ICF Core Sets are sets of categories out of the International Classification of Functioning, Disability and Health (ICF) which can serve as minimal standards for the assessment, communication and reporting of functioning and health for clinical studies, clinical encounters and multi-professional comprehensive assessment and management. The ICF Core Sets were developed in a formal decision-making and consensus process, integrating evidence gathered from preliminary studies and expert opinion. The Acute ICF Core Sets for patients with neurological, musculoskeletal and cardiopulmonary conditions are intended for use by physicians, nurses, therapists and other health professionals working in the acute hospital on medical, surgical or other units not specialised in rehabilitation. The Post-acute ICF Core Sets for geriatric patients and patients with neurological, musculoskeletal or cardiopulmonary conditions are intended for use by physicians, nurses, therapists and other health professionals involved in early post-acute rehabilitation. The Acute and Post-acute ICF Core Sets are first versions and need to be tested and validated in the patient and professional perspective and in different countries, regions, health care and provider settings.     

Validation of the Comprehensive ICF Core Set for obstructive pulmonary diseases from the perspective of physiotherapists

Background and Purpose. The ‘Comprehensive ICF Core Set for obstructive pulmonary diseases’ (OPD) is an application of the International Classification of Functioning, Disability and Health (ICF) and represents the typical spectrum of problems in functioning of patients with OPD. To optimize a multidisciplinary and patient‐oriented approach in pulmonary rehabilitation, in which physiotherapy plays an important role, the ICF offers a standardized language and understanding of functioning. For it to be a useful tool for physiotherapists in rehabilitation of patients with OPD, the objective of this study was to validate this Comprehensive ICF Core Set for OPD from the perspective of physiotherapists. Method. A three‐round survey based on the Delphi technique of physiotherapists who are experienced in the treatment of OPD asked about the problems, resources and aspects of environment of patients with OPD that physiotherapists treat in clinical practice (physiotherapy intervention categories). Responses were linked to the ICF and compared with the existing Comprehensive ICF Core Set for OPD. Results. Fifty‐one physiotherapists from 18 countries named 904 single terms that were linked to 124 ICF categories, 9 personal factors and 16 ‘not classified’ concepts. The identified ICF categories were mainly third‐level categories compared with mainly second‐level categories of the Comprehensive ICF Core Set for OPD. Seventy of the ICF categories, all personal factors and 15 ‘not classified’ concepts gained more than 75% agreement among the physiotherapists. Of these ICF categories, 55 (78.5%) were covered by the Comprehensive ICF Core Set for OPD. Conclusion. The validity of the Comprehensive ICF Core Set for OPD was largely supported by the physiotherapists. Nevertheless, ICF categories that were not covered, personal factors and not classified terms offer opportunities towards the final ICF Core Set for OPD and further research to strengthen physiotherapists' perspective in pulmonary rehabilitation. Copyright © 2009 John Wiley & Sons, Ltd.     

Identification of problems in the functioning of individuals with schizophrenia from the expert perspective: an Internet-based survey

Purpose: The purpose of the study was to identify aspects of functioning and related environmental factors that are relevant to schizophrenia from the perspective of health professionals experienced in treating individuals with this disorder using the International Classification of Functioning, Disability and Health (ICF).

Method: An international pool of experts from diverse health care disciplines was surveyed to identify problems in functioning experienced by individuals with schizophrenia and the environmental factors that impact their functioning. On the basis of established rules, all answers were translated to the ICF by two independent researchers.

Results: One-hundred and eighty-nine experts from all six World Health Organization regions identified 4776 meaningful concepts, of which 92% were linked to 347 different ICF categories. Of the 347 categories, 194 were second-level categories, 151 were third-level categories and 2 were fourth-level categories. Ninety-five second-level ICF categories, 43 third-level categories and 1 fourth-level category reached percentage frequency of at least 5%. The majority of the categories were attributed to body functions, activities and participation, and environmental factors.

Conclusions: Health professionals identified a wide range of problems in functioning that reflect the complexity and breadth of schizophrenia, specifically activity limitations and participation restrictions that are particularly relevant for individuals with schizophrenia. Knowing these functioning problems can guide the design of patient-oriented rehabilitation programmes.

• Implications for rehabilitation

• Schizophrenia may result in impaired functioning in multiple daily life activities. The International Classification of Functioning, Disability and Health (ICF) can help in identifying the needs and problems of these individuals.

• The reported list of ICF categories can facilitate a systematic application of the ICF in schizophrenia and can help to design and implement coordinated and patient oriented rehabilitation programmes with a biopsychosocial approach.

• According to health professionals surveyed, activity limitations and participation restrictions are broadly affected in this population and are highly influenced by neurocognitive and social cognitive deficits and environmental factors.

     

运用ICF评定肌肉骨骼系统健康状况的影响

目的建议联合使用国际疾病分类(ICD)及国际功能、残疾和健康分类(ICF),并应用肌肉骨骼系统(MSK)状况的例子来说明运用方法。方法根据在ICD中MSK状况的分类和现有的ICF核心分类集(ICF Core Sets)MSK状况的类目作为备选类目来专门说明专项功能。另一方法是考虑来自在文献中出现的已经应用的测量方法或工具的类目。结果从6个MSK状况的核心分类集、两种特定的保健治疗环境、一种MSK临床研究环境和8篇工具相关的文献中抽取相关的ICF类目。结论 ICD-ICF联合使用通过考虑疾病和功能状况来强调健康状况的影响,从而促进临床保健治疗。因此,有证据显示,在ICD修订版背景下ICD和ICF之间有可操作性的联系和互补作用。     

Simplified bipartite concepts of functioning and disability recommended for interdisciplinary use of the ICF

Abstract

Purpose: To argue for and propose bipartite concepts of functioning and disability, to tally with the structure of the ICF classification list, concepts of social models and clinical needs. Method: The ICF concepts are discussed in relation to the history of ideas regarding disability concepts and the needs for such concepts in interdisciplinary rehabilitation. Results: Bipartite concepts are presented; they refer to actual functioning, simply body functions/structures and participation, including functioning in standardized environments. Participation refers to actually performed “activities”, with “activities” simply denoting things that people may do. Bipartite concepts are congruent with the ICF classification and the structure of social models of disability, suitable for clinical and interdisciplinary use and easy to understand. The issue of standardized environments represents a methodological issue rather than the conceptual issue of defining functioning and disability. An individual perspective on activity and activity limitations, i.e. the middle part of the tripartite ICF concept, is somewhat similar to concepts of traditional language that were regarded as too generalizing already in 1912, when the interactional concept of “disability in a social sense” was introduced in rehabilitation practices. Conclusion: Bipartite concepts of functioning and disability are recommended for interdisciplinary use of the ICF.

• Implications for Rehabilitation

• The ICF classification is useful, but the ICF concept of activities in an individual perspective is confusing.

• We suggest a use of the term “activities” simply to denote things that people may do and “participation” to denote actually performed activities.

• Estimations of ability should be explicit about how they are related to environmental factors.

     

脑卒中评估中《国际残损、残疾和残障分类》的应用问题

对《国际残损、残疾和残障分类》(ICF)的基本概念和ICF与ICIDH-1区别进行介绍,讨论在脑卒中评估中将ICF作为评测的基本框架。建议在评估时按照ICF的基本框架组织安排脑卒中评估的内容。同时也对在脑卒中评估时应用ICF遇到的问题,尤其是ICF的限定值与现存脑卒中量表的量化标准以及ICF与脑卒中生存质量模型的关系进行探讨。     

ICF Core Set for patients with musculoskeletal conditions in the acute hospital

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with musculoskeletal conditions in the acute hospital.

Methods: The ICF Core Set development involved a formal decision-making and consensus process integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.

Results: Twenty-one experts selected a total of 47 second-level ICF categories. The largest number of categories was selected from the ICF component Body Functions (17 categories or 36%). Nine (19%) of the categories were selected from the component Body Structures, 11 (23%) from the component Activities and Participation, and 10 (21%) from the component Environmental Factors.

Conclusion: The Acute ICF Core Set for patients with musculoskeletal conditions provides all professionals with a clinical framework to comprehensively assess patients in the acute hospital. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.     

ICF Core Set for patients with neurological conditions in the acute hospital

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with neurological conditions in the acute hospital.

Methods: The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.

Results: Twenty-one experts selected a total of 85 second-level categories. The largest number of categories was selected from the ICF component Body Functions (41 categories or 48%). Five (6%) of the categories were selected from the component Body Structures, 18 (21%) from Activities and Participation and 21 (25%) from Environmental Factors.

Conclusions: The Acute ICF Core Set for patients with neurological conditions provides all professionals with a clinical framework to comprehensively assess patients in the acute hospital. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.     

ICF Core Set for patients with cardiopulmonary conditions in the acute hospital

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with cardiopulmonary conditions in the acute hospital.

Methods: The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.

Results: Twenty-two experts selected a total of 48 second-level categories. The largest number of categories was selected from the ICF component Body Functions (21 categories or 44%). Four (8%) of the categories were selected from the component Body Structures, 10 (21%) from the component Activities and Participation, and 13 (27%) from the component Environmental Factors.

Conclusion: The Acute ICF Core Set for patients with cardiopulmonary conditions provides all professionals with a clinical framework to comprehensively assess patients in the acute hospital. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.     

ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities

Purpose: The aim of this consensus process was to decide on a first version of the ICF Core Set for patients with musculoskeletal conditions in early post-acute rehabilitation facilities.

Methods: The ICF Core Set development involved a formal decision-making and consensus process integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients.

Results: Fifteen experts selected a total of 70 second-level categories. The largest number of categories was selected from the ICF component Body Functions (23 categories or 33%). Seven (10%) of the categories were selected from the component Body Structures, 22 (31%) from the component Activities and Participation, and 18 (26%) from the component Environmental Factors.

Conclusion: The Post-acute ICF Core Set for patients with musculoskeletal conditions is a clinical framework to comprehensively assess patients in early post-acute rehabilitation facilities, particularly in an interdisciplinary setting. This first ICF Core Set will be further tested through empiric studies in German-speaking countries and internationally.     

Validation of the extended ICF core set for stroke from the patient perspective using focus groups

Purpose: The extended international classification of functioning, disability and health (ICF) core set for stroke is an application of the ICF of the World Health Organisation (WHO) with the purpose to represent the typical spectrum of functioning of persons with stroke. The objective of the study was to add evidence to the validation of the extended ICF core set for stroke from the perspective of patients using focus groups to explore the aspects of functioning and health important to persons with stroke. Method: The sampling of patients followed the maximum variation strategy. Sample size was determined by saturation. The focus groups were digitally recorded and transcribed verbatim. After qualitative data analysis, the resulting concepts were linked to ICF categories and compared to the categories included in the extended ICF core set for stroke. Results: Sixty patients participated in 15 focus groups. The content of 131 out of 166 ICF categories contained in the extended ICF core set for stroke was reported by the persons with stroke. The content of 31 additional categories that are not covered in the extended ICF core set for stroke was raised. Conclusions: The existing version of the extended ICF core set for stroke could be confirmed almost entirely from patient perspective.

Implications for Rehabilitation:

• The extended ICF Core Set for stroke can be used to create a functioning profile for persons after stroke to identify problems and resources considering a client-centred approach.

• This study shows which aspects of the environment of persons after stroke are relevant from the clients’ perspective and should be integrated in the rehabilitation process.

• This study provides a basis for the further development of the ICF, especially with regard to its update in relevant aspects from clients’ perspective after stroke.

     

Blending activity and participation sub-domains of the ICF

Objective. The objective of the study was to test the supposition that distinct Activity and Participation sub-domains of the International Classification of Functioning, Disability, and Health (ICF) could be identified using physical function questionnaire items drawn from the Activity and Participation Measures for Post Acute Care.

Design. A cross-sectional survey design was employed.

Subjects. The sample consisted of 272 patients who had received post acute care across inpatient and community care settings during the previous year.

Methods. Exploratory factor analysis with oblique rotation was used to identify interpretable dimensions underlying 83 physical functioning questionnaire items.

Results. Factor analysis findings revealed five distinct ICF conceptual sub-domains that explained 61% of the total variance of the data, with root mean square residual equal to 0.089. These domains were labeled: (i) Daily activity, (ii) Applied cognitive, (iii) Role participation, (iv) Mobility, and (v) Social participation. These five factors were correlated to varying degrees and achieved acceptable levels of internal consistency with coefficient alphas from 0.59 – 0.93.

Conclusion. These analyses suggest that clear distinctions between Activity and Participation sub-domains of the ICF could not be identified in a sample of adults who had recently received post acute care. We believe this is important evidence of the ability to measure blended Activity and Participation sub-domains that cut across distinct and interpretable areas of life functioning.