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Author Response
The ICF and physical therapy
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Sean D Rundell, Physical Therapist Portland Sports Medicine and Spine Physical Therapy, Portland, Oregon, Todd E Davenport and Tracey Wagner
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sean{at}pdxspine.com Sean D Rundell, et al.
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We would like to thank Dr Escorpizo and Dr Cieza for their interest in and response to our case report on applying the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) to the physical therapist management of low back pain (LBP).1 Although an important difference between the Nagi model2 and the ICF model3 includes bidirectional relationships among nonhierarchical domains of function, the WHO’s figure representing the ICF model is still visually linear. We determined that a figure that was less linear would better represent our perceived application of the ICF model in this case report. As mentioned in Escorpizo and Cieza’s response, we did view the health condition as a component that simultaneously interacts with all the other components of the model. Additionally, we saw health condition as the greater issue to which we were applying the ICF model for each patient. All the domains in this figure are demonstrated to interact with each other by way of overlap and bidirectional arrows. Ample references to the literature, including the ICF itself, were provided in our article to guide readers who are unfamiliar with the ICF model. The Journal’s readers can decide the clinical relevance of any differences in depiction of the ICF model between our article and others in the literature. We agree that there is a direct relationship between contextual factors and activity. An arrow representing the bidirectional relationship between contextual factors and activity limitations was present in our original Figure 1. Unfortunately, a printing error resulted in omission of this important component. We are currently working with the Journal’s editors to provide a corrected version of this figure. The additional brief description of the ICF model’s use as a conceptual model, classification approach, and the ICF core sets4 by Escorpizo and Cieza is appreciated. In our case report, the ICF model was applied to describe the disablement experience for each patient and to assist in the clinical reasoning for each patient’s case. The ICF core set concept was briefly applied in Table 1 and, with a couple of additions, in Table 2 for categorization of the body function and structure impairments, activity limitations, participation restrictions, and contextual factors. We believe that core sets and the International Classification of Disease-10 (ICD-10) classification5 are important content from the perspective of determination and the study of general trends in clinical management of LBP at the population level. We decided that this depth of information was less essential to satisfy our objective of introducing the Journal’s readership to the process of applying the ICF in the management of individual patients with LBP. Therefore, we think a detailed discussion of the use of the ICF model core sets and the ICD-10 remains beyond the intended scope of this case report. We agree that these topics are highly relevant. The derivation and description of guidelines describing practice related to common musculoskeletal health conditions is the subject of ongoing work within the Orthopaedic Section of the American Physical Therapy Association.6–8 Using this work and existing core sets for patients with LBP, we believe future mixed methods studies would be better positioned to optimally describe best practices related to physical therapists’ use of the ICD-10 classification and core sets derived from the ICF model, rather than our case report. In the management of the patient with chronic LBP, several environmental factors related to her work were identified by the physical therapist. These environmental factors were not addressed for intervention because they were deemed unable to be changed or extremely difficult to change. A description of an intervention directed to the domain of environmental factors in the “Intervention” section was not included because no intervention was directed to that domain. It is unclear how the lack of intervention directed at this domain or the manner in which it was documented in our case report resulted in any discrepancy between physical therapist management and the ICF model. Instead, we think this highlights the inherently inexact science of applying any conceptual model of clinical management to a specific patient’s case. We are optimistic that our documentation of this experience can contribute to future conceptual and empirical work in this important area for rehabilitation research. Sean D Rundell, Todd E Davenport, and Tracey Wagner References 1 Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization’s International Classification of Functioning, Disability and Health. Phys Ther. 2009;89:82–90. 2 Nagi S. Disability and Rehabilitation. Columbus, OH: Ohio State University Press; 1969. 3 International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 4 Cieza A, Stucki G, Weigl M, et al. ICF Core Sets for low back pain. J Rehabil Med. 2004(44 suppl):69–74. 5 International Classification of Diseases (ICD-10). Available at: http://www.who.int/classifications/icd/en/. 6 Irrgang JJ, Godges J. Use of the International Classification of Functioning and Disability to develop evidence-based practice guidelines for treatment of common musculoskeletal conditions. Orthopaedic Physical Therapy Practice. 2006;18(4):24–25. 7 McPoil TG, Martin RL, Cornwall MW, et al. Heel pain-plantar fasciitis: clinical practice guidelines linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A18. 8 Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38:A1–A34. |
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Reuben Escorpizo, Physical Therapist and ICF Core Set Project Leader Swiss Paraplegic Research (SPR) and ICF Research Branch SPR site, Alarcos Cieza
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reuben.escorpizo{at}paranet.ch Reuben Escorpizo, et al.
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We have read with interest Rundell and colleagues' case report on the International Classification of Functioning, Disability and Health (ICF) and its application to low back pain (LBP).[1] The article clearly presented the role of the ICF as a unifying framework that clinicians and researchers (eg, in clinical trials) can use. It also solidified the role of physical therapists’ clinical-decision making skills in effectively managing patients on the basis of the ICF. However, we have some comments regarding the way they have represented the conceptual model of functioning and disability behind the ICF and practical tools developed based on this classification, such as the ICF Core Sets. Figure 1 does not represent the official depiction of the model as it is in the ICF book[2] and can be misleading. The health condition in their figure seems to represent a background experience that directly interacts with all other components of the model. In addition, although the possible direct relationship between contextual factors and activity was mentioned in the text, it was not represented in the figure. The authors did not provide any further explanation of the need for and usefulness of the changes made to the original model. On one hand, readers who are not familiar with the ICF might have the impression that the authors' presented model is the official model. On the other hand, readers who are familiar with the ICF would have difficulty understanding the rationale behind the changes that were made. It probably would have been helpful to introduce explicitly the difference between the ICF as a model and the ICRF as a classification. The model has 6 interrelating components of health: health condition, body functions and structures, activities, participation, environmental factors, and personal factors. The ICF classification concretizes all of the components except for health conditions and personal factors in the form of ICF categories. The ICF contains a total of 1,454 categories, which are hierarchically organized. Health conditions are classified in the International Classification of Diseases (ICD-10).[3] Thus, the ICD-10 and the ICF are complementary classifications, and the World Health Organization envisions a common application of these classifications in clinical medicine and research. The authors mentioned the ICF Core Set for LBP.[4] However, they did not state its value for clinical practice and research. An ICF Core Set is a list of ICF categories relevant to people with a health condition or health-related event, such as LBP. Thus, the ICF Core Set for LBP contains all areas of functioning that are evaluated and treated by all health care professionals, including physical therapists, as part of a multidisciplinary team. The ICF Core Sets represent the basis to guide multidisciplinary assessment and treatment.[5,6] Finally, in the case description of the use of the ICF model in physical therapist management for the patient with chronic LBP, environmental factors were identified, but not in the "Intervention" section and not until later in the "Outcome" section, thus leaving a gap between the ICF and physical therapist management. Reuben Escorpizo, PT, DPT, Swiss Paraplegic Research (SPR), Nottwil, Switzerland, and ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI) SPR site Alarcos Cieza, PhD, MPH, Swiss Paraplegic Research (SPR), Nottwil, Switzerland; ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI) SPR site; and ICF Research Branch of the WHO Collaborating Center for the Family of International Classifications at the German Institute of Medical Documentation and Information (DIMDI), IHRS, Ludwig-Maximilian University, Munich, Germany References 1. Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic low back pain using the World Health Organization's International Classification of Functioning, Disability and Health. Phys Ther. 2009;89:82-90. 2. International Classification of Functioning, Disability and Health: ICF. Geneva, Switzerland: World Health Organization; 2001. 3. International Classification of Diseases (ICD-10). Available at: http://www.who.int/classifications/icd/en/. 4. Cieza A, Stucki G, Weigl M, et al. ICF core sets for low back pain. J Rehabil Med Suppl. 2004;36:69-74. 5. Allet L, Cieza A, Burge E, et al. Intervention categories for physiotherapists treating patients with musculoskeletal conditions on the basis of the International Classification of Functioning, Disability and Health. Int J Rehabil Res. 2007;30:273-280. 6. Rauch A, Cieza A, Stucki G. How to apply the International Classification of Functioning, Disability and Health (ICF) for rehabilitation management in clinical practice. Eur J Phys Rehabil Med. 2008;44:329-342. |
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