Fundamental Considerations of Patient Interaction and the ICF Framework

The International Classification of Functioning, Disability and Health (ICF)

  • Framework Overview: The International Classification of Functioning, Disability and Health (ICF) is the World Health Organisation (WHO) framework designed for measuring health and disability at both the individual and population levels across the entire lifespan.
  • Classification Basis: It classifies health and health-related domains using a common language for disability.
  • Aetiology Neutrality: The framework is aetiology neutral, meaning there is no explicit or implicit distinction between different health conditions. Disability is not differentiated based on its cause or origin.
  • Conceptualisation: Functioning is conceptualised as a ‘dynamic interaction between a person’s health condition, environmental factors and personal factors.’
  • Standardisation: It provides a standard language, conceptual basis, classifications, and codes for the definition and measurement of disability.
  • Bio-Psycho-Social Synthesis: The ICF integrates the major models of disability—the medical model and the social model—into a cohesive "bio-psycho-social synthesis."
  • Umbrella Terms: Functioning and disability are understood as umbrella terms that denote the positive and negative aspects of functioning from biological, individual, and social perspectives.

ICF Organisation and Key Definitions

  • Structure of Information: The ICF puts everyone in a context: functioning and disability result from the interaction between health conditions and the environment. It organises information into two parts, each with two components:
    • Part 1: Functioning and Disability
      • Body functions and body structures.
      • Activities and participation.
    • Part 2: Contextual Factors
      • Environmental factors.
      • Personal factors.
  • Core Definition of Functioning: An umbrella term for body functions, body structures, activities, and participation. It denotes the positive aspects of the interaction between an individual with a health condition and their contextual factors (environmental and personal).
  • Core Definition of Disability: An umbrella term for impairments, activity limitations, and participation restrictions. It denotes the negative aspects of the interaction between an individual with a health condition and their contextual factors.

Detailed Components of the ICF Model

  • Body Structures: Anatomical parts of the body defined in eight categories:
    1. Structures of the nervous system.
    2. The eye, ear, and related structures.
    3. Structures involved in voice and speech.
    4. Structures of the cardiovascular, immunological, and respiratory systems.
    5. Structures related to the digestive, metabolic, and endocrine systems.
    6. Structures related to the genitourinary and reproductive system.
    7. Structures related to movement.
    8. Skin and related structures.
  • Body Functions: The physiological functions of body systems categories:
    1. Mental functions (e.g., orientation, energy, drive).
    2. Sensory functions (e.g., vision, hearing, pain).
    3. Voice and speech functions.
    4. Functions of the cardiovascular, hematological, immunological, and respiratory systems.
    5. Functions of the digestive, metabolic, and endocrine systems.
    6. Genitourinary and reproductive functions.
    7. Neuro-musculoskeletal and movement-related functions (e.g., joint mobility, muscle strength, endurance).
    8. Functions of the skin and related structures (e.g., sensation, protection).
  • Impairments: Defined as a problem in body structures or functions. Key characteristics:
    • Manifestation of pathology (not the pathology itself).
    • Can be temporary or permanent.
    • Can be progressive or non-progressive.
    • Can be continuous or intermittent.
  • Activity and Participation:
    • Activity: The execution of a task or action by an individual.
    • Activity Limitations: Difficulties an individual may have in executing activities.
    • Participation: Involvement in a life situation.
    • Participation Restrictions: Problems an individual may experience in involvement in life situations.
    • Domains: 1. Learning and knowledge application; 2. General duties; 3. Communication; 4. Mobility; 5. Self-care; 6. Domestic life; 7. Interpersonal interactions; 8. Major life areas (work/education); 9. Community/social life.
  • Contextual Factors:
    • Environmental Factors: The physical, social, and attitudinal environment in which people live. These include: 1. Products and technology; 2. Natural/human-made environment; 3. Attitudes; 4. Services, systems, and policies; 5. Support and relationships.
    • Personal Factors: Factors influencing how disability is experienced, including age, gender, beliefs, perspectives, culture, socioeconomic status, education, and occupation.

The ICF in Physiotherapy Practice

  • Clinical Reasoning: This is the process where physiotherapists collect cues, process information, understand a patient's problem, plan interventions, evaluate outcomes, and reflect. The ICF facilitates this by integrating information about health conditions, impairments, and functional limitations to create context-appropriate programs.
  • Physiotherapy Assessment:
    • Subjective Examination: Gains information on structure, function, impairment, activity, participation, and contextual factors.
    • Physical (Objective) Examination: Specifically focuses on body structures, body function, and activity.
  • Outcome Measures: Tools used to assess a patient’s current status. They serve as adjuncts to examination, provide baseline data, guide goal setting, and support Evidence-Based Practice (EBP).
  • Categories of Outcome Measures:
    1. Self-reported measures: Questionnaires (Fixed or adaptive) capturing patient perceptions of health or function (Patient-Reported Outcomes or PRO).
    2. Observer-reported measures: Completed by a proxy (e.g., caregiver).
    3. Performance-based measures: Patient performs specific tasks; scores are objective or qualitative.
    4. Clinical-based measures: Completed by the therapist using clinical judgment to guide intervention planning.

Psychometric Properties and Measure Selection

  • Norm-referenced Measures: Evaluates a trait and estimates an individual's position in a predefined population (compares to peers). Usually involves quantitative scoring and strict instructions.
  • Criterion-referenced Measures: Determines what an individual can/cannot do against set standards or minimum competence levels. Can be qualitative or quantitative.
  • Psychometric Definitions:
    • Reliability: Consistency or repeatability of a measurement.
    • Validity: The extent to which an instrument measures what it is intended to measure.
    • Sensitivity (SnOUT): Ability to correctly identify those with a condition (True Positive). If negative, it helps Rule Out (SnOUT).
    • Specificity (SpIN): Ability to correctly identify those without a condition (True Negative). If positive, it helps Rule In (SpIN).
    • Responsiveness: Ability to detect change.
    • Minimal Important Difference: The amount of change required for the results to be clinically relevant.

Clinical Measurement Tools

  • Impairment Tools (Body Structure and Function):
    • Amnesia: Galveston Orientation and Amnesia Test (GOAT); Westmead PTA Scale.
    • Ataxia/Coordination: SARA; Finger-Nose Test.
    • Dizziness: Dizziness Handicap Inventory (DHI).
    • Muscle Tone/Spasticity: Tardieu; Modified Ashworth Scale; SCI-SET; ArmA; LegA.
    • Strength: Motricity Index; Dynamometer (grip).
    • Pain: Numerical Rating Scale (NRS); Visual Analogue Scale (VAS); WUSPI; Ritchie Articular Index.
    • Other: Goniometer (ROM); RASP/Nottingham (Sensation); Palpation (Subluxation).
  • Activity Measure Tools:
    • Mobility: 10m10\text{m} Walk Test; 66 Minute Walk Test; Timed Up and Go (TUG); Dynamic Gait Index (DGI); HiMAT; DEMMI.
    • Balance: Sitting Balance Test; CTSIB; Functional Reach; Step Test; Berg Balance Scale; Mini-BESTest.
    • Falls: Falls Diary; Falls Efficacy Scale (FES); ABC Scale.
  • Participation/Global Function Tools:
    • Participation: Goal Attainment Scale (GAS); CASP; WHOQOL-BREF; SF-36 Health Status Questionnaire.
    • Global Function: Functional Independence Measure (FIM); Functional Assessment Measure (FAM).

Case Study: Perspectives on Osteoarthritis (OA)

  • Disease Perspective:
    • Prevalence: >1.8×106>1.8 \times 10^6 Australians (8%8\%).
    • Characterised as chronic, inflammatory, and degenerative, primarily affecting synovial joint articular cartilage.
    • Leads to bony remodeling (spurs/lipping) and joint effusion.
    • Symptoms: Pain after activity, stiffness after rest, crepitus, reduced ROM.
    • Risk Factors: Obesity, joint trauma, muscle weakness, female gender, family history.
  • Functioning Perspective (ICF):
    • Body Functions/Structures: Pain sensation, impaired mobility, fatigue, reduced muscle power, depression.
    • Activities: Reduced walking ability, difficulty with hand/arm use, self-care difficulties.
    • Participation: Unable to work, social withdrawal.
    • Contextual: Family dependence, need for home modifications, financial dependency, fear of falling.

The Therapeutic Partnership

  • Definition: The interaction where a patient (seeking healing) and a physiotherapist (healing agent) invest in a relationship to relieve suffering and disability while addressing beliefs and attitudes.
  • Evidence-Based Benefits:
    • Increased patient satisfaction.
    • Improved rehabilitation engagement and treatment adherence.
    • Improved function, mood, and patient-reported pain.
  • Founding Principles:
    1. Duty of Care: Act in the best interest of the patient.
    2. Power: Unequally held by the therapist due to expertise and access to private info.
    3. Respect: Accepting patient values and morals.
    4. Trust: Professional skills must address patient needs.
    5. Sensitivity: Required to protect trust.

Professional Boundaries and Relationship Comparisons

  • Professional vs. Personal Relationships:
    • Money: Professional involves financial compensation; Personal is shared care.
    • Duration: Professional is limited to treatment; Personal may be lifelong.
    • Location: Professional is limited to treatment site; Personal is anywhere.
    • Purpose: Professional is for physiotherapy service; Personal is for pleasure.
    • Structure: Professional is organised/scheduled; Personal is unstructured.
    • Power: Professional is unequal; Personal is shared.
    • Responsibility: The physiotherapist is primarily responsible for maintaining the professional relationship.
  • Boundaries in Regional/Rural Practice: Practitioners often have pre-existing business or personal ties with community members. Risks include compromised objectivity, assumptions, patient dishonesty, and conflicts of interest.

Effective Communication in Physiotherapy

  • Expressive Component Meaning Breakdown:
    • Body language: 55%55\%.
    • Tone of voice: 38%38\%.
    • Language (words): 7%7\%.
  • Question Types:
    • Open: Invites narrative, builds rapport.
    • Closed: Definitive yes/no; clarifies specific info.
    • Graded-response: Illustrates condition/ability better.
    • Reflective: Reflects feelings; empathetic.
    • Leading/Testing: Used to establish competence/direct info.
  • Active Listening: Involves concentration, eye contact, and interested body language. Functions include clarifying meaning, checking accuracy of the message, and checking the speaker's feelings.

Interaction Procedures: AIDET and Consent

  • AIDET Tool:
    • A - Acknowledge: Safety and respect.
    • I - Introduce: Decrease anxiety.
    • D - Duration: Increase cooperation.
    • E - Explanation: Quality.
    • T - Thank You: Value and respect.
  • Patient Identification: Use 3 approved identifiers (Name, DOB, Gender, Address, or Record Number). Required at making appointments, arrival, telephone contact, or when accessing records.
  • Informed Consent: Obtaining permission before examination, treatment, or teaching. Must include advising of potential costs.
  • Verbatim Interview Consent Script: ‘For the interview today, I will be asking you personal questions relating to your injury and how your injury impacts on your activities of daily living. The more information you provide, the more likely it is that I can provide effective treatment. It is your choice as to what information you choose to provide. I will adhere to the privacy and confidentiality act and will treat your personal information with the upmost respect. If you feel uncomfortable with a question, or group of questions, please let me know at any time and I will stop. Do you consent to this interview?’
  • Verbatim Physical Examination Consent Script: ‘During this examination, it will be necessary for me to make physical contact with you. I may also require you to remove some items of your outer clothing so that I may examine your affected body areas effectively. Where possible, I will always use a towel to keep body areas not being examined covered. If you feel uncomfortable, please let me know at any time and I will stop. Do you consent to this examination?’