ICF and PT Process

Medical

Medical

▪ it views disability as a feature of a person,
directly caused by the disease
▪ disability on this model, calls for medical or
other treatments to correct the problem with
the individual
▪ thus it appears in this model that disability is
somewhat internal to the person
▪ result of the disability of an individual; internal

Disability is always an interaction between features of the person and features of the overall context in which the person lives social phenomenon

Feature of the person, directly caused by the disease, trauma or other health condition requiring medical care provided by individual professionals

Social

▪ it sees disability as socially created and not at
all attributed to the person
▪ disability demands political response, because
the problem is created by unaccommodating
physical environment brought about by
attitude and society
▪ It describes this ability externally
▪ societal views and attitudes, created by social
norms or standards

Socially created problem (not an attribute of the individual), demanding a political response created by unaccomodating physical environment, attitude, and social environment

Disability

o both a problem at the level of a person's body and a
complex social phenomenon
o interaction of different factors both internal to the
person and external like the environment

Biophysical model

integrates the features of the
person and feature of the overall context in which the
person lives

biopsychosocial

due to the interaction of medical and social it is formed
to describe disability

Nagi Model of Disability

Describe health status to categorize clinical
observations systematically.
• The earlier model
• reflects that disability may or may not be the result of
interaction
• disability may or may not be a result of the interaction
of the person's physical or mental impairments with the
society or the environment.
• disability has three distinct but interrelated concepts:

Active pathology

▪ interruption of normal cellular processes of an
organism (human) to regain a normal state
▪ can be brought about by infection, trauma,
metabolic imbalance degenerative processes
or other etiologies or causes
• cellular problems or interruptions because
of disease or it could be at an organ level

Impairment

▪ Can be any damage to the body structures
anatomically or body functions physiologically
▪ Examples: muscle weakness, decreased
cardiovascular endurance
• Body functions are processes affected, leads
to the functional limitation

Functional limitation

▪ represents restriction in the basic activities a
person performs daily
▪ Example: walking, bed mobility, or transfers
• difficulty in performing societal roles and
interrupt activities
• actions slowly done, hold on to something
to get up

Active pathology: a businessman presenting with
low back pain

brought about by accumulation of lactic
acid on back muscles or ligamentous
strain/sprain

Impairment

pain on low back area, weakness of
the trunk extensor muscles, limited trunk motion

Functional limitation

difficulty walking, inability to carry heavy loads, difficulty in getting in and out of the bed

THE ICIDH-WHO MODEL OF DISABILITY

• Describe health status to categorize clinical
observations systematically.
• Developed in the 1970s
• International Classification of Impairment, Disability,
and Handicap
• This framework differentiates a series of related
concepts just like NAGI's model.
• originally drafted to code and manipulate data on the
consequences of a health condition

Active Pathology --> Disease

o still refer to affectation of cellular processes

Impairment

o still refers to an atomic structures and physiologic
processes of the body that were affected by the
disease

Functional limitations --> disability

o describes activities that are limited due to the
impairments
o Basic ADLs are any form of local motion done
every day
o activities needed to be done daily

handicap

counterpart of disability in Nagi

simple linear progression

Both the disablement models of Nagi and ICIDH present
being incapacitated

disablement

-is a static and unidirectional process according to these early frameworks.
-which is not the case, as it has varying
courses and severity across the life span of an
individual.

Why is there a need for ICF?

For health planning and management purposes.
o primarily used for planning and policy tool for
decision makers
• Determine the overall health of populations, the
prevalence and incidence of non-fatal health outcomes,
and to measure health care needs and the performance
and effectiveness of health care systems.
o Medical classification of diagnosis alone will not
have the information that we need for health
planning and management purposes because it
lacks data about levels of functioning and
disability
• disability is multi factorial and an interconnection of
different categories
o its nature is dynamic and complex

INTERNATIONAL CLASSIFICATION OF FUNCTIONING,
DISABILITY AND HEALTH (ICF)

o Disablement model of the World Health
Organization (WHO) as their framework for
health and disability.
o Standard language and framework for the
description of health and health-related states
▪ Provides a standardized form of
communication to health care providers for
health allied professionals to understand
each other even if they are from different
practices
▪ Example: a PT can understand an OT or a
medical doctor using this framework in
describing health and other related
concepts
o The conceptual basis for the definition,
measurement and policy formulations for health
and disability.
▪ it is also used in policymaking in any health
sector because it provides universal
classification of disability and health
o It is a universal classification of disability and
health for use in health and health-related
sectors.

The ICF Model (2002)

• This shows the complexity and dynamism of disable
men as the arrow represent in the relation between the
different domains and factors
• Disability include the function of patients
• diagram could be expressed positively or negatively,
hence its neutrality
• activity limitation can lead to impairment and vice versa
• multi factorial and dynamic

functioning and disability

▪ body structures and functions
▪ activities
▪ participation

contextual factors

▪ environmental factors
▪ personal factors

Health condition

Refers to the disease, disorders or injuries of the
person.

MUSCULOSKELETAL

Ankle sprain, Low back pain, Cervical strain, Transtibial amputation;

NEUROLOGIC

stroke, spinal cord injury, multiple
sclerosis, Bell's palsy;

CARDIOPULMONARY

chronic bronchitis, myocardial infarction, or
coronary artery bypass grafts

Contextual factors

(Can influence a patient's recovery;
could help in creating a prognosis)

Environmental (external)

o social attitudes, architectural characteristics,
legal and social structures, as well as climate,
terrain and other factors in which people live and
conduct their lives
o Example: a person suffering from a severe case of
lower back pain who have a good social support
its a good prognostic factor
o environmental set up such as using stairs is a poor
prognostic factor
▪ stair negotiation exercises should be used
as a treatment plan if the patient uses the
stairs
▪ if the patient has no problem is stairs these
exercises should be removed
o Examples: lives with parents, trains most days,
two story house, commuter, classes on the
second and third floor of a building

Personal (internal)

o gender, age, coping styles, social background,
education, profession, past and current
experience, overall behaviour pattern, character
and other factors that influence how disability is
experienced by the individual

Gender

-some diseases has gender
preference
• Example: scoliosis is prevalent in
females and it's a good prognosis
since you don't need to research
much on it because it is already
expected; when males have scoliosis,
it is a poor prognosis since it is not
commonly seen on men and it could
be caused by any underlying
conditions
• stroke is common in males thus it is a
good prognosis; if a 34 year old
female experiences stroke, it is a poor
prognosis since females have
estrogen to protect them from
cardiovascular diseases

Age

good prognosticating factor because
if the patient is young the capacity to
recover is high but if the patient is old it is a
poor prognostic factor

stress level

a poor prognostic factor if a
person has high levels of stress because
there could be an influx of hormones that
could hinder recovery

coping mechanism

-if a person has a good coping mechanism it is a good prognostic factor
-they should also be culturally accepted
because if it is not or if it is a taboo, it is a
poor prognosis

good coping mechanism

motivated to get well, compliant, actively researches
about the disease, seek alternative
management, alternative medicine (oils,
etc help patient psychologically) -- hence
a good prognosis

Hypertension

• high blood pressure
• it is a personal factor because it
cannot be treated by means of
physical therapy interventions
• only medications can address this
which is beyond the scope of a
physical therapist
• if the condition could not be treated
with physical therapy intervention,
we don't include it as a health
condition
• as physical therapists, we don't have
direct intervention or exercise that
can lower a person's blood pressure

IMPAIRMENTS (level of body or body part)

o How is the person's body affected?
o problems in body function or structure such as a
significant deviation or loss

BODY STRUCTURES

are anatomical parts of the body such as organs, limbs and their components

BODY FUNCTIONS

are physiological functions of body systems (including
psychological functions)

ACTIVITY LIMITATIONS (whole person)

o How does the problem affect the person's life?
o difficulties an individual may have in executing
activities.
o Can include limitations in the performance of
cognitive and learning skills, communication
skills, functional mobility skills and basic activities
of daily living (BADLs)
o Common to all people regardless of factors in
conditions; depends on context of action

ACTIVITIES

execution of a task or action by an individual

PARTICIPATION RESTRICTIONS (whole person in a social
context)

o are problems an individual may experience in
involvement in life situations and social
interactions including home management, work
(job/school/play) and community/leisure.
o a disadvantage for a given individual resulting
from an impairment or a disability that limits or
prevents the fulfillment of a role that is normal
o these includes instrumental activities of daily
living (IADLs)

PARTICIPATION

involvement in a life situation

instrumental activities of daily living (IADLs)

▪ Refers to the person's hobbies, occupation,
and recreation
▪ tasks related to occupation, leisure, etc

Carpal tunnel syndrome

- basic activities such as
eating is not affected, but preparation of meals
are affected since the grip and force are greatly
required to do this

Qualifiers

• record the presence and severity of a problem in
functioning at the body, person and societal levels
(three domains)

PERFORMANCE QUALIFIERS

- describes what an individual does in his or her current environment
o Extent of difficulty in performing tasks which can
range from mild to moderate to severe to
complete

CAPACITY QUALIFIERS

- describes an individual's ability
to execute a task or an action indicating the highest
probable level of functioning
o Can range from the assistance of a device or
another person or environmental modification

Universality

o applicable to all people irrespective of health
condition.
o It concerns everyone and should not become a
tool for labeling persons with disabilities as a
separate group
o you can be disabled even if you are perfectly
normal

PARITY

o there should not be, explicitly or implicitly, a
distinction between different health conditions as
'mental' and 'physical' that affect the structure of
content of a classification of functioning and
disability.
o refers to the equivalence between different
health conditions whether mental or physical
o disability must not be differentiated by etiology
or cause

NEUTRALITY

o domain names should be worded in neutral
language so that the classification can express
both positive and negative aspects of each aspect
of functioning and disability.
o Neutral language of the domains, to be expressed
both positively and negatively
o unlike the earlier models of NAGI and the ICIDH,
wherein disability began where health and
placing that person with disability in a separate
category, ICF focuses on the person's ability to function in the society despite having the
impairments

ENVIRONMENTAL FACTORS

o essential aspect of the scientific understanding of
the phenomena included under the umbrella
terms 'functioning and disability'.

Steps in Patient/Client Management

• follow a certain process for us to better address the
patient/client's needs

Physical therapists

must always exercise sound clinical decision
making.

Clinical reasoning

-involves a wide range of cognitive skills to process patient/client data
-is the internal dialogue that a PT constantly use whenever they face a patient/client.

Examination

• Involves identifying and defining the patient's
problem(s) and the resources available to determine
appropriate intervention
• Immediately starts upon referral or initial
entry and continues all throughout until the end of
patient care. Initial examination provides general
overview of the patient's condition

Ongoing or re- examination

o assess the patient's progress and response to
treatment to give room for adjustments or
modifications of the plan of care.

History

-Information about the patient's past history and
current health status is obtained from review of
the medical record and interviews.
o Interviewing a patient or client is an important
tool to obtain information and gain knowledge
directly from the patient or client about their past
history and current health status

SYSTEMS REVIEW

o Scanning the patient's body systems and
determine areas of intact function and
dysfunction in each of the following systems:
cardiovascular/pulmonary, integumentary,
musculoskeletal, and neuromuscular, cognitive
functions, communication, learning style, and
emotional status.
o quick screening is done to confirm the need for
further examination, rule out other conditions,
referral to other health professionals and to focus
on the origin of the patient complains

Tests and Measures

o Provide objective data to accurately determine
the degree of specific function and dysfunction.
o More definitive examination procedures are done
to accurately determine the degree of affectation
and dysfunction. Within the scope of our practice
as PTs we can perform examination procedures to
further cement our working hypothesis about the
condition of our patient
o Includes:
▪ postural assessment
▪ sensory assessment
▪ range of motion assessment
▪ muscle testing and functional assessment

Evaluation

• Identifies and prioritizes the patient's impairments,
activity limitations, and participation restrictions and
develops a problem list
• Impairments, activity limitations, and participation
restrictions must be analyzed to identify causal
relationships.
o to identify which problem is the primary culprit
and which manifestations are the result of this
causative factor.
• Determining the causative factors may be difficult but it
is essential so as to help the PTs formulate the most
appropriate intervention scenario and treatment plan.
o Example: a patient coming in for PT services
complains of difficulty in walking because of pain
on the legs. The PT then, examines the patient to
look for problems that can be addressed
▪ Is the pain caused by a muscular problem or
is it vascular in origin?
▪ What type of pain is felt?
▪ Is the muscle weak?
▪ Are there any limitations in the movements
of the knee and ankle joints?

Diagnosis

• Identify the impact of a condition on function at the
level of the system (especially the movement system)
and at the level of the whole person.
o we can diagnose a patient as long as our diagnosis
is within the scope of our practice
o our main concern is the functional ability of our
patient that is being hindered by a condition and
the associated signs and symptoms.
• Elaboration of the medical diagnosis to identify altered
physical status focusing on functional consequences
o Comparing it with a medical diagnosis which is a
call given by Medical Doctors and focuses at the
cellular level by identifying the pathology of the disease or disorder, PT diagnosis is centered at
the level of the whole person

Prognosis

• Predicted optimal level of improvement in function and
amount of time needed to reach that level
• an accurate prognosis can be given even at the early
stages of treatment
• Other times, prediction of level of improvements is
done during the course of the treatment process
especially in complicated cases.
• Prognosticating grades that we give to our patients
which is of course dependent on several factors such as
severity of the disease, age of the patient, presence of
co-morbidities, disease progression and others:

EXCELLENT

presents potential to fully recover with no residual deficit

GOOD

present potential to improve to the
status of functional independence with certain
minimal limitation

FAIR

presents potential to improve in some
areas while other deficit areas may remain
impaired

Poor

limited potential for improvement

GUARDED

there is a question of the potential
for improvement

Intervention

Purposeful interaction of the physical therapist with the
patient/client and, when appropriate, other individuals
involved in the care of the patient/client, using various
physical therapy procedures and techniques to produce
changes in the condition.

Communication Coordination and Documentation

▪ Patient management requires effective
communication with the patient and the
rehabilitation team, proper coordination for
correct and quick referral whenever needed and accurate as well as updated documentation helps
in the collaborative effort of the healthcare team
in patient recovery

Patient/Client-Related Instructions

▪ provide one on one instruction to patients,
clients, relatives or caregivers. Sometimes, group
discussion or with the use of printed or digital
materials are also employed by therapist to
educate
▪ part of our treatment plan because this ensures
successful transition to the home or work
environment

RESTORATIVE

- remediating or improving the
patient's status in terms of impairments,
activity limitations, participation restrictions,
and recovery of function
• Examples: strengthening exercises to treat
muscle weakness, hot compress to manage
pain, stretching exercises to improve range
of motion etc.

COMPENSATORY

- promoting optimal function
using residual abilities
• Example: training a stroke patient with right
sided paralysis to write using the left hand
or strengthening the arms of a child who
cannot walk to use it for crawling

PREVENTIVE

- minimizing potential problems
and maintaining health
• Examples: arranging the workstation to
prevent possible occurrence of muscle
strains or upper extremity bike ergometer
on patients with spinal cord injury to
prevent deterioration of cardiovascular
endurance due to immobility and paralysis
of the lower limbs

Outcomes/Re-examination

-Involves continuous re-examination of the patient and
a determination of the efficacy of treatment
o ongoing and repetitive process to evaluate the
effectiveness of the interventions given to the
patient or client
• Results of patient/client management, which include
the impact of physical therapy interventions
o If the patient is progressing and then plateaus,
the therapist re-examine to modify the exercise
and make them more challenging to the patient
o if the patient manifests regression, the PT again
re-examines and adjusts the treatment plan by
decreasing the intensity of exercises or removing
some interventions completely