Dr. J. Reinhardt - Intern. Klassifikation ICF als übergreifendes Konzept

Die Internationale Klassifikation der 

Funktionsfähigkeit, Behinderung und 

Gesundheit (ICF) 

als Paradigma, Standard und 

Werkzeug in der Rehabilitation 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 2011 1

Affiliations Dr. Jan D. Reinhardt 

Swiss Paraplegic Research, Nottwil, Switzerland 

University of Lucerne, Department of Health 

Sciences and Health Policy 

International Society of Physical and 

Rehabilitation Medicine, Secretary WHO Liaison 

Committee, Vice Chair Rehabilitation Disaster 

Relief Committee 

WHO ICF Research Branch of the German WHO 

CC (DIMDI), Munich, Germany & Nottwil, 

Switzerland 


Überblick 

1. Das ICF Paradigma und Modell 

2. Struktur der ICF als Klassifikation 

3. ICF Coding 

4. Linking Methode und Entwicklung von ICF Core Sets 

5. Praktische Anwendung der ICF in der Kinder- und 

Jugendrehabilitation 

6. Ausblick 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 2011 

Einführung 

3

Fragen an das Publikum 

Wer hat eines dieser Bücher schon einmal in der Hand 

gehabt bzw. entsprechende Internetressourcen 

genutzt? 


4


Wer benutzt die ICF oder ICF-CY in der 

klinischen oder epidemiologischen 

Forschung? 


5


Wer benutzt die ICF oder ICF-CY in der (klinischen) 

Praxis, z.B. für Assessment/Evaluation von 

Patientenstatus und Therapieerfolg? 


Assessment 

Global Goal: 

Serv.-Progr.-Goal: Increase independence in daily routine 2 

Cycle goal 1: Mobility 2 

Cycle goal 2: Self-Care 2 

ICF categories ICF Qualifier Goal Re- Goal 

Body functions, body structures, activities and participation 

0 

problem 

1 2 3 4 

lation value 

b152 Emotional functions SPG 1 

b280 Sensation of pain CG1 1 

b440 Respiration functions 

b525 Defecation functions 

b620 Urination functions 

b710 Mobility of joint functions CG1 0 

b730 Muscle power functions CG1 2 

b735 Muscle tone functions CG1 1 

b810 Protective functions of the skin 

s120 Structure of the spinal cord and related structures 

s430 Structure of the respiratory system 

s610 Structure of the urinary system 

s810 Structure of areas of skin 

d230 Carrying out daily routine SPG 2 

d240 Handling stress and other psychological demands 

d410 Changing basic body positions CG1 2 

d420 Transferring oneself CG1 2 

d440 Fine hand use CG1 1 

d445 Hand and arm use 

d455 Moving around 

d465 Moving around using equipment CG1 1 

d470 Using transportation CG1 2 

d520 Caring for body parts CG2 1 

d530 Toileting CG2 2 

d550 Eating 

d570 Looking after one’s health CG2 1 

d710 Basic interpersonal interactions 

d720 Complex interpersonal interactions 

d920 Recreation and leisure 

Environmental factors 

facilitator 

4+ 3+ 2+ 1+ 0 1 

barrier 

2 3 4 

e110 Products or substances for personal consumption 

e115 Products and techn. for personal use in daily living CG2 +4 

e120 Products and techn. for personal…mobility CG1 +4 

e150 Design, construction…of buildings for public use 

e310 Immediate family 

e340 Personal care providers 9 

e355 Health professionals 

e460 Social attitudes 

e580 Health services, systems and policies 

6


Was ist die ICF? 

• Ein Paradigma/eine Theorie/ein Modell 

• Eine Klassifikation 

• Ein Kommunikationsmedium 

• Ein Medium der klinischen und populationsbasierten Forschung 

• Ein klinisches Werkzeug? 

7

1. Das integrative bio-psycho-soziale Model 

von Funktionsfähigkeit und Behinderung 


ICF als Paradigma 

Gesundheitsproblem 

Funktionsfähigkeit Körperfunktion und Behinderung 

Aktivitäten Partizipation 

en/-strukturen 

Umweltfaktoren Personbezogene 

Faktoren 

Understanding Functioning and Disability 

8

1. The ICF integrative bio-psycho-social model of functioning and 

disability 

ICF integrates individual/medical and social models of 

disability. 

Health 

condition 

Disability 

Society/ 

environment 

Medical model 

Body functions/ 

Body structures 


Health condition 

Activities Participation 

Environmental factors Personal factors 

Health 

condition 

Disability 

Society/ 

environment 

Social Model 

9

The ICF focuses on the lived experience of persons with health 

conditions 

Impaired 

Body functions and 

structures 

Person‘s 

experience of 

disability in 

relation to the 

body 


Limited 

Activities 

& Restricted 

Participation 

Patient‘s 

experience of 

disability in 

relation to the 

environment


disability 

The lived experience is 

reflected at the levels 

of… 

Participation 

E.g.,Taking care of 

others 

Activities 

E.g., Manipulating 

objects 

Body Functions 

E.g., Mobility and 

stability of joints 

Body Structures 

E.g., Joints (hands, 

fingers) 

= Functioning and Disability 

…in interaction with 

the environment. 


11

Functioning and disability may range from… 

Integrity in 

Body functions 


Activities and 

Participation 

Complete 

functioning 

Functioning and Disability as Continuum 


Impairments in 



Limitations in 

Activites and 

Restrictions in 

Participation 

Complete 

disability 

12


disability 

Environmental 

factors 


Personal factors 

An individual’s functioning in a specific domain is an interaction or 

complex relationship between the health condition and 

contextual factors. 



disability 

Environmental 

factors 

Rheumatoid Health arthritis, condition ICD M05 


There is a dynamic and cumulative interaction between the entities: 

Changes in one entity can modify one or more of the other entities. 



disability 

Environmental 

factors 

Coxarthrosis, Health condition ICD M16 


The interaction works in two directions; the presence of disability may 

even modify the health condition itself 



disability 

Environmental 

factors 



It is important to collect data on these constructs independently 

and thereafter explore associations and causal links between them. 



disability 



Environmental 

factors 



Personal 

factors 

• Integrates medical and 

social models 

• Integrates various 

perspectives of 

functioning (biological, 

individual and social) 

• Is a multidimensional 

model (Body functions 

and structures, 

Activities, Participation) 

• Is an interactive model 

rather than a linear 

progressive model 

• Reflects dynamic 

interactions among the 

components 



disability 

ICF is an universal model and applies to all people 

irrespective of their culture, health condition, gender, or age. 

Instead of making disability a distinguishing mark of a discrete 

minority group, the ICF describes all the domains of functioning 

and disability that are applicable to everyone. 


? 

18


disability 

The ICF original version had neglected some aspects important 

to children and youth as well as education and pediatric 

rehabilitation. Therefore, the ICF-CY was created. 

•The ICF-CY is derived classification. 

•ICF-CY has additional categories such as play and preschool 

education. 

•ICF-CY has incorporated developmental delay in definition of 

impairment and activity limitation qualifiers. 

• ICF-CY has modified several exclusion and inclusion criteria 

for particular categories. 


19

F:\Bilder\Barcelona 09\Barcelona\DSC_0023.JP G 

2. ICF als Klassifikation 



ICF as classification 

2. The structure and codes of the 

classification 

Functioning and Disability 


Structures 

b110 - 

b899 

b1100 - 

b7809 

b11420 - 

b51059 

s110 - 

s899 

s1100 - 

s8309 

s11000 - 

s76009 

d110 - 

d999 

d1550 - 

d9309 

ICF 


Participation 

b1 – b8 s1 – b8 d1 – d9 e1 – e5 

Contextual factors 

Environmental 

factors 

e110 - 

e599 

e1100 - 

e5959 

Personal 

factors 

Describing Functioning and Disability 

21

2. The structure and codes of the ICF 

Typically, classification is the placing of similar objects 

into groups 


22

Hierarchical structure 



Andere 

Möglichkeiten? 

23


493 384 



310 


Environmental factors Personal factors 

253 


The integrative bio-psycho-social model of functioning and disability is 

the basis for the ICF classification. 

There are large numbers of factors grouped into the components of the 

ICF model (except the personal factors). 

classified 

within ICD 

0 



Activites & participation 





Functioning and Disability Contextual factors 


Structures 

Body 

functions 

b110 - 

b899 

b1100 - 

b7809 

b11420 - 

b51059 

Body 

structures 

s110 - 

s899 

s1100 - 

s8309 

s11000 - 

s76009 


Participation 

d110 - 

d999 

d1550 - 

d9309 

Environmental 

factors 

b1 – b8 s1 – b8 d1 – d9 e1 – e5 

e110 - 

e599 

e1100 - 

e5959 

b 110 s54002 54002 d4401 4401 

e1101 

1101 

Parts 

Components 

Chapters 

Second-level classification 

Third-level classification 

Fourth-level classification 

ICF code = Prefixes + Numeric codes + ICF Qualifiers 

Personal 

factors 

Not 

classified 

yet! 



An ICF code is composed of a prefix, the numeric code and 

an ICF Qualifier. 

The letter denotes the component of the classification and 

the number of digits indicates the level of detail of the 

category. 

Component s 

Chapter 

2nd level 

73020 

3rd level 

4th level 



The classification provides a 

standard language and a 

common framework for the 

description of health and 

health related domains 

“ICF does not classify 

people, but describes the 

situation of each person 

within an array of health or 

health-related domains.” 

(WHO 2001:8) 


27

1 

b2 

b3 

b4 

b5 

b6 

b7 




Structures 

Body 

functions 


Body 

structures 

Mental functions 


Participation 

Sensory functions and pain 

Voice and speech functions 

Jan D. Reinhardt, b8 Functions 

PhD; Berchtesgaden 

of the skin 

1/14 

and 

2011 

related structures 

Environmental 

factors 

Chapters 

Functions of the cardiovascular, haematological, immunological and 

respiratory functions 

Functions of the digestive, metabolic and endocrine system 

Genitourinary and reproductive functions 

Neuromusculoskeletal and movement-related functions 


Personal 

factors 

28

s1 

s2 

s3 

s4 

s5 

s6 

s7 




Structures 

Body 

functions 


Body 

structures 


Participation 

Structures of the nervous system 

The eye, ear and related structures 

Environmental 

factors 

Structures involved in voice and speech 

Personal 

factors 

Structures of the cardiovascular, immunological and respiratory 

system 

Structures related to the digestive, metabolic and endocrine system 

Structures related to the genitourinary and reproductive system 

Structures related to movement 

Chapters 


Jan D. Reinhardt, PhD; Berchtesgaden s8 Skin and 1/14 relates 2011 structures 

29


Mental functions 

Sensory functions and pain 

Voice and speech functions 

Functions of the cardiovascular, haematological, 

immunological and respiratory functions 

Functions of the digestive, metabolic and 

endocrine system 

Genitourinary and reproductive functions 

Neuromusculoskeletal and movementrelated 

functions 

Functions of the skin and related structures 

Body functions Body structures 

b1 

b2 

b3 

b4 

b5 

b6 

b7 

b8 

s1 Structures of the nervous system 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 2011 30 

s2 

s3 

s4 

s5 

s6 

s7 

s8 

The eye, ear and related structures 

Structures involved in voice and speech 

Structures of the cardiovascular, 

immunological and respiratory system 

Structures related to the digestive, 

metabolic and endocrine syste 

Structures related to the genitourinary 

and reproductive system 

Structures related to movement 

Skin and related structures




Structures 

Body 

functions 



Participation 

Body 

structures d1 

d2 

d3 

d4 

d5 

d6 

d7 

d8 

Environmental 

factors 

Learning and applying knowledge 

General tasks and demands 

Communication 

Mobility 

Self-care 

Domestic life 

Personal 

factors 

Interpersonal interactions and relationships 

Major life areas 

Chapters 

Activity and 

participation 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 d9 2011 Community, social and civic life 

31




Structures 

Body 

functions 


Body 

structures 


Participation 

Products and technology 

Natural environment/human-made changes to the environment 

Support and relationship 

Attitudes 

Services, systems and policies 

Environmental 

factors 

Personal 

factors 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 2011 32 

e1 

e2 

e3 

e4 

e5 

Chapters 

Environmental 

factors


The hierarchical structure of the classification allows either a broader 

(chapter or 2 nd level classification) or a more specific (3 rd or 4 th 

level classification) description of functioning. Broader categories 

include the more detailed categories of the parent category. 

Within each domain, the specificity of the description of an ICF 

category increases. 

For each category (2 nd , 3 rd or 4 th level) you can find a definition 

(except in the component of Body structures) together with inclusion 

and exclusion criteria. 


33

Example: 



210 Seeing functions 




Structures 

Body 

functions 

b1 

b2 Sensory functions 

b2 

and pain 

b3 

b4 

b5 

b6 

b7 

b8 


Body 

structures 

b215 

b220 

b229 

b230 

b235 

b240 

b249 

b250 

b255 

b260 

b265 

b270 

b280 


Participation 

b2100 

b2101 

b2102 Quality of vision 

b2108 

b2109 

Seeing functions of sensing a 

minimum amount of light (light 

minimum), and the minimum 

difference in intensity (light 

difference) 

Environmental 

factors 

Inclusion: functions of dark adaptation; 

impairments such as night blindness 

(hyposensitivity to light) and photophobia 

(hypersensitivity to light) 

b21020 Light sensitivity 

b21021 Colour vision 

Personal 

factors 

b21022 Contrast sensitivity 

b21023 Visual picture quality 

b21028 Quality of vision, other 

specified 

b21029 Quality of vision, unspecified 



The WHO provides an online ICF Web- 

Browser where the classification can be 

searched for ICF categories: 

http://www.who.int/classifications/icfbrowser 


Component s 


ICF as Classification 

3. Coding with the ICF 

Chapter 

2nd level 

7 3020.4 

2 

3rd level 

1 st qualifier 

2 nd qualifier 

3 3 rd qualifier 

4th level 

37


3. Coding with ICF qualifiers 

The use of any ICF category should be accompanied by at 

least one qualifier. Without qualifiers, codes have no 

inherent meaning. 

Qualifiers denote the magnitude of the level of health or 

severity of the problem at issue. Qualifiers are coded as one, 

two or more numbers after a point. 

s73020.4 2 

1st qualifier 

2nd qualifier 

3 3 rd qualifier 

Having a problem may mean an impairment, limitation or 

restriction or barrier depending on the ICF construct. 

38



Structures 

Body 

functions 

Body 

structures 



Participation 

XXX.0 NO problem (none, absent, negligible,…) 0 – 4% 

XXX.1 MILD problem (slight, low,...) 5 – 24% 

XXX.2 MODERATE problem (medium, fair...) 25 – 49% 

XXX.3 SEVERE problem (high, extreme,...) 50 – 95% 

XXX.4 COMPLETE problem (total,...) 96 – 100% 

XXX.8 not specified (the available information does not suffice to specify the 

severity of the problem) 



Environmental 

factors 

XXX.9 not applicable (it is inappropriate or not possible to apply the code) 




structures 

Body 

functions 

Body 

structures 

XXX.0 NO barrier 

XXX.1 MILD barrier 

XXX.2 MODERATE barrier 

XXX.3 SEVERE barrier 

XXX.4 COMPLETE barrier 




Participation 


Environmental 

factors 

XXX+0 NO facilitator 

XXX+1 MILD facilitator 

XXX+2 MODERATE facilitator 

XXX+3 SEVERE facilitator 

XXX+4 COMPLETE facilitator 

XXX.8 barrier, not specified XXX+8 facilitator, not specified 

XXX.9 not applicable XXX+9 not applicable 


Here are some examples of the use of the generic ICF Qualifier: 



Eating is a fair 

problem (it 

takes much 

more time) 

d550.2 b7101.3 

I am able to 

work only parttime 

as a 

translator 

d850.2 e310+4 

The mobility in the 

ankle joints is severely 

impaired 

My mother is an 

extreme support for me 

41


ICF qualifier for activities and participation 

Performance 

Describes what an individual does in his 

current environment. This context 

includes the environmental factors – all 

aspects of the physical, social and 

attitudinal world which can be coded 

using the environmental factors 

component 

s7501.413 

=Complete impairment with total 

absence of structures of both lower 

legs 

d4552.XX 04 

=Running 

Capacity 

Describes an individual’s ability to 

execute a task or an action. This 

construct aims to indicate the 

highest probable level of functioning 

that a person may reach in a given 

domain at a given moment in a 

standard environment, i.e. without 

environmental factors such as 

assistive devices. 



ICF qualifier for activities and participation 

Performance 

Describes what an individual does in his 

current environment. This context 

includes the environmental factors – all 

aspects of the physical, social and 

attitudinal world which can be coded 

using the environmental factors 

component 

b230.3 

=Severe impairment in Hearing 

functions 

d310.XX 03 

Communicating with – 

receiving – spoken 

messages 

Capacity 

Describes an individual’s ability to 

execute a task or an action. 

This construct aims to indicate 

the highest probable level of 

functioning that a person may 

reach in a given domain at a 

given moment 


Using the ICF Qualifiers a functioning profile can be created. 

This gives a description of the complete experience of 

functioning. 

ICF categories ICF Qualifier 

problem 

0 1 2 3 4 

b134 Sleep functions 

b152 Emotional functions 

b28013 Pain in back 

b4350 Immune response 

b610 Urinary excretory fucntions 

b710 Mobility of joint functions 

b735 Muscle tone functions 

b755 Involuntary movement reaction functions 



d230 Carrying out daily routine 


d410 Changing basic body positions 

d4153 Maintaining a sitting position 

d420 Transferring oneself 

d465 Moving around using equipment 

d475 Driving 

d540 Dressing 


facilitator barrier 

4+ 3+ 2+ 1+ 0 1 2 3 4 


e115 Assistive products… for personal use in daily living 

e120 Assistive products…for personal mobility 

e155 Design, construction…of buildings for private use 




44

4.1 Linking health and health related information to the ICF 

The linking methodology allows the use the ICF 

standard vocabulary to facilitate 

• understanding the meaning of health and health 

related information 

• comparsion of information from different 

sources 


J Rehabil Med 2002~ 34: 205-210 

SPECIAL REPORT 

LINKING HEALTH-STATUS MEASUREMENTS TO THE INTERNATIONAL 

CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH 

Alarcos Cieza, Thomas Brockow , Thomas Ewert, Edda Amman, Barbara Kollerits, 

Somnath Chatterj , T. Berdihan Üstün and Gerold Stucki 

From the Department of Physical Medicine and Rehabilitation, University of Munich, Munich, Spa Medicine Research 

Institute, Bad Elster, Germany and Classification, Assessment, Surveys and Terminology Team, World Health Organization, 

Switzerland. 

With the approval of the International Classification of Functioning, Disability and Health by the World Health Assembly in May 2001, 

the concurrent use of both healthstatus measures and the International Classification of Functioning, Disability and Health is expected. 

It is therefore important to understand the relationship between these two concepts. The objective of this paper is to provide a 

systematic and standardized approach when linking healthstatus measures to the International Classification of Functioning, Disability 

and Health. The specific aims are to develop rules, to test their reliability and to illustrate these rules with examples. Ten linking rules 

and an example of their use are presented in this paper. The percentage agreement between two health professionals for 8 healthstatus 

instruments tested is also presented. A high level of agreement between the health professionals reflects that the linking rules 

established in this study allow the sound linking of items from health-status measures to the International Classification of Functioning, 

Disability and Health. 

Keywords: ICF, health-status measures, linking rules. 

J Rehabil Med 2002; 34: 205-210 

Correspondence address: Alarcos Cieza, Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians Universit , Munich, 

Germany E-mail: Alarcos.Cieza @ phys.med.uni-muenchen.de 

Submitted June 18, 2002; Accepted June 20, 2002 

© 2002 Taylor & Francis. ISSN 10-50-/977 


T aylor&Francis 

healthsciences 

J Rehabil Med 34

4.1 Linking health and health related information to the ICF 

Disability QoL / Satisfaction 

Nordic Sleep Questionnaire 

Q1. Have you had any 

difficulties in falling asleep? 

What was your level of need 

for help with not sleeping well? 

Supportive Care Needs Survey 


b134 Sleep functions 

WHOQoL-BREF 

F3.3 How satisfied are you 

with your sleep? 

I didn`t lose any sleep, 

but I needed tablets. 

Aberdeen Low Back Pain Scale 

Needs Dependency 

Introduction to the ICF

From ICF to clinical practice 

4.2 Development of ICF Core Sets 

s110 

s120 

s130 

s430 

s510 

s710 

… 

b110 

b114 

b117 

b130 

b152 

b144 

b730 

... 

d110 

d240 

d410 

d415 

d520 

d630 

d920 

… 

e110 

e115 

e120 

e125 

e130 

e150 

… 


s110 

s430 

s710 

b110 

b130 

b152 

b730 

d240 

d410 

d415 

d920 

e110 

e120 

e130 

Health conditions 

specific, situation 

specific 

48

Entwicklung von ICF Core Sets 

ICF Core Sets 

Ein ICF Core Set ist eine Liste von ICF Kategorien, 

die so wenig Kategorien wie möglich, jedoch so viele 

wie nötig umfasst, um alle relevanten Aspekte der 

Funktionsfähigkeit von Menschen mit einer 

spezifischen Gesundheitstörung und in einem 

spezifischen Kontext für ein umfassendes und 

multidisziplinäres Assessment zu beschreiben. 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 2011

Preparatory Phase 

What problems of persons with the 

Empirical 

Clinical 

health condition are found in clinical 

multicenter practice? Perspective study 

Systematic 

Researchers’ 

literature reported Perspective 

in the literature? review 


health condition are measured and 

Qualitative Patients’ study 

from Perspective 

their perspective? 

What are the problems that persons 

with the health condition experience 

Experts’ survey via 


health condition are considered 

relevant by the health professionals 

email 

that Perspective 

treat them? 

Health professionals’ 



Phase I 

International ICF 

consensus 

conference 

1st version of the 

ICF Core Set 

Year 1 Year 2 

Phase II 

Testing and 

Validation of the 

1st version of the 

ICF Core Sets

Health conditions 



� 

nkylosing spondylitis 

� 

reast cancer 

� 

hronic ischemic heart disease 

� 

hronic widespread pain 

� 

epression 

� 

iabetes 

� 

and conditions 

� 

ead and Neck Cancer 

� 

ow back pain 

� 

ultiple sclerosis 

�

Current developments 



� Amputees 

� Bipolar disorders 

� Burns 

� Cerebral Palsy 

� Inflammatory bowel Diseases 

� Traumatic Brain Injury 

� Vocational Rehabilitation

• Comprehensive ICF Core Set 

List of ICF categories that includes as few categories as 

possible to be practical, but as many as necessary to 

describe the aspects of functioning relevant to persons 

with a specific condition in a comprehensive, multidisciplinary 

assessment 


4.2 Development of ICF Core Sets

• Brief ICF Core Set 

List of ICF categories that serves as the minimal 

standard for reporting the functioning of persons 

with a specific health condition along the continuum of 

care (ranging from the acute hospital to rehabilitation 

facilities and community) and across sectors (health, 

education, labour and social affairs) 



Keep in mind: 

…What to measure 

and not 


ICF Core Sets define… 

…How to measure 


Value of ICF Core Sets 

• Guide for clinical assessment 

– Minimum functioning catalogue: 

What to assess? 

– What are the patient’s problems? 

• Basis for improving communication 

– Among professionals 

– Between settings 



Actual situation …. 



Patient 

Nurses‘ diagnosis 

Nursing Interventions 

Nursing 

documentation 

___________ 

___________ 

___________ 

PT diagnosis 

PT Interventions 

PT 

documentation 

____________ 

____________ 

____________ 

Physician‘ diagnosis Physician 

Interventions 

Physician 

documentation 

____________ 

____________ 

____________ 

OT diagnosis 

OT Interventions 

OT 

documentation 

____________ 

____________ 

____________ 

Ψ diagnosis 

Ψ Interventions 

Ψ 

documentation 

__________ 

__________ 

__________

Aim and vision…. 



Patient 

Nurses‘ diagnosis 

Nursing Interventions 

Nursing 

documentation 

___________ 

___________ 

___________ 

PT diagnosis 

PT Interventions 

PT 

documentation 

____________ 

____________ 

____________ 

ICD-10 


____________ 

____________ 

____________ 

Physician‘ diagnosis Physician 

Interventions 

Physician 

documentation 

____________ 

____________ 

____________ 

OT diagnosis 

OT Interventions 

OT 

documentation 

____________ 

____________ 

____________ 

Ψ diagnosis 

Ψ Interventions 

Ψ 

documentation 

__________ 

__________ 

__________

5. Using the ICF in rehabilitation management 

Theory �� Practice 


Evaluation 

Assessment 

Rehab-Cycle 

Intervention 

Assignment


At the core of rehabilitation care provision are the 

evolving problems and needs of individuals in 

relation to functioning. 

To achieve or maintain optimal function a 

multidisciplinary approach is required. Hence, 

rehabilitation integrates medical approaches 

labor, educational, social, architectural etc. 

approaches through cooperation and professionals 

across sectors. 



Use case 

ICF based rehabilitation management 

in an in-patient rehabilitation program for adolescents 

with Spina Bifida and Cerebral Palsy 



Assessment of a patient‘s functioning status within the ICF 

Categorical Profile: A case example 

A person with Spina Bifida 

• 17 year old adolescent 

• Living with his family 

• Visiting regular school 

• Hobbies: Impassioned 

panpipe-player, reading, listen 

to music, computer 


62

6.2. Using the ICF in rehabilitation management 

Stefan‘s medical history 

1991: Congenital lumbal meningomyelocele with Arnold-Chiari- 

Maldeformation type 3, sub L3 

1993 Hydrocephalus, Shunt Hydrocephalus, Shunt revision 

2000 Luxation of both hip joints, surgery (Stefan was able to stand 

and walk a little bit before the surgery, Pressure ulcer 

2002 Tethered cord syndrome, Lumbal untethering 

2004 Tethered cord syndrome, Cervical untethering (laminektomy 

C2/C3 and C1) 

2004 Scoliosis, Spondylodesis Th3 to S1 (lead to stiffened spine) 

2005 Scoliosis, Dorsal spondylodesis C2 to C5 (lead to stiffened spine) 

2006 Traumatic SCI ASIA C, C6 (Epiduralhämatom, Skibob accident), 

surgery 



Assessment of a patient‘s functioning status within the ICF 

Categorical Profile: A case example 

„I don‘t like speed“ 

„My mother is doing 

everything – and then she 

says ‚Do it on your own‘ - 

but at the same breath she is 

doing it.“ 

„ I always have to rush about – 

…on the other hand, one could 

also say: ‚My family is too fast“ 

Health insurance agreed to pay for Stefan‘s participation in a three week inpatient 

rehabilitation program. This program aims to increase the 

independence of adolescents with congenital or traumatic spinal cord injuries. 


64


Assessment of functioning 

Test: Muscle 

power functions 

Observation: Caring 

for body parts 

Examination: 

Transferring 

oneself 


Assessment 

Global Goal: 

Service-Program-Goal: 

Cycle goal 1: 

Cycle goal 2: 

ICF categories ICF Qualifier Goal Re- 


0 

problem 

1 2 3 4 

lation 

b152 Emotional functions 

b280 Sensation of pain 





b730 Muscle power functions 

b735 Muscle tone functions 






d230 Carrying out daily routine 




d440 Fine hand use 




d470 Using transportation 

d520 Caring for body parts 

d530 Toileting 

d550 Eating 

d570 Looking after one’s health 





facilitator 

4+ 3+ 2+ 1+ 0 

barrier 

1 2 3 4 


e115 Products and technology for personal use in daily living 

e120 Products and technology for personal…mobility 



e340 Personal care providers 




Goal 

value

ICF Categorical Profile 

Result 

Assessment 

Global Goal: 

Serv.-Progr.-Goal: Increase independence in daily routine 2 

Cycle goal 1: Mobility 2 

Cycle goal 2: Self-Care 2 



0 

problem 

1 2 3 4 

lation value 

b152 Emotional functions SPG 1 

b280 Sensation of pain CG1 1 




b710 Mobility of joint functions CG1 0 

b730 Muscle power functions CG1 2 

b735 Muscle tone functions CG1 1 






d230 Carrying out daily routine SPG 2 


d410 Changing basic body positions CG1 2 

d420 Transferring oneself CG1 2 

d440 Fine hand use CG1 1 



d465 Moving around using equipment CG1 1 

d470 Using transportation CG1 2 

d520 Caring for body parts CG2 1 

d530 Toileting CG2 2 

d550 Eating 

d570 Looking after one’s health CG2 1 





facilitator 

4+ 3+ 2+ 1+ 0 1 

barrier 

2 3 4 


e115 Products and techn. for personal use in daily living CG2 +4 

e120 Products and techn. for personal…mobility CG1 +4 



e340 Personal care providers 9 





ICF Assessment 

Sheet 

ICF Evaluation 

Display 



Assessment 

Evaluation Rehab-Cycle 

Intervention 

ICF Categorical 

Profile 

Assignment 

ICF Intervention 

Table

B o d y fu n c tio n /s 

tru c tu re 

A c tiv ity / P a rticip ation 

E n v iro n m en - 

ta l facto rs 

P e rs o n al 

fa c to rs 

Intervention targets MD Nu PT OT Ps 

rs y 

X 

b280 Sensation of pain 


b7300 Power of isolated muscles 

b7305 Power of muscles of the trunk X 

b7353 Tone of muscles of lower half X X 

b755 Involuntary movement reactions X 


d4153 Maintaining a body position 


d475 Driving 

d510 Washing oneself 


d540 Dressing 

d570 Looking after one‘s health 

d850 Remunerative employment 

e115 Products and techn. for use in daily 

e120 Products and techn. for mobility 

e155 Design, construction of buildings 

pf Coping with disease 

pf Acceptance of emotions 

Jan D. Reinhardt, PhD; Berchtesgaden 1/14 X2011 

pf Self competencies 

X X 

X 

X X 

X 

X 

X X X 

X 

X 

S 

W 

X X 

X X X X X X 

X 

Oth Intervention First 

value 

Manual therapy 

2 

X 

X 

X X 

X X X 

X 

X 

Active and passive movement of joints 

Muscle power training with equipment 

Muscle power training without equipment 

Medication, Hippotherapy, Water therapy 

Movement reaction training 

Training of activites of daily living 

Muscle power training, movement reaction tr. 


Driving training 


Training of activites of daily living, Counselling 


Education, Counselling, 

Vocational training 

Choice and adaptation of assistive devices 

Choice and adaptation of wheelchair 

Clarification of living situation (private build.) 

Other psych. therapy, Psych. counselling 



0 

1 

2 

2 

3 

3 

2 

2 

4 

1 

2 

3 

2 

4 

+3 

+2 

4 

+ 

- 

- 

Goal 

value 

0 

0 

1 

0 

1 

1 

1 

1 

1 

2 

0 

1 

0 

1 

3 

+4 

+4 

2 

+ 

0 

0 

Final 

value


Keep in mind: 

The ICF Intervention Table… 

1… provides an overview of the assignment of 

interventions to intervention targets and to the 

different health professionals. 

2… illustrates the required resources 


ICF Assessment 

Sheet 

ICF Evaluation 

Display 



Assessment 

Evaluation Rehab-Cycle 

Intervention 

ICF Categorical 

Profile 

Assignment 

ICF Intervention 

Table


Evaluation of the changes in the functioning status (in 

intervention targets) following the rehabilitative interventions 

Assessment Evaluation 

Global Goal: 

Serv.-Progr.-Goal: Increased independence in daily routine 2 - 

Cycle goal 1: Mobility 2 � 

Cycle goal 2: Self-Care 2 - 


ICF Qualifier 

Goal 

0 

problem 

1 2 3 4 

lation value 

0 

problem 

1 2 3 4 

achievement 

b152 Emotional functions SPG 1 � 

b280 Sensation of pain CG1 1 � 

b710 Mobility of joint functions CG1 0 - 

b730 Muscle power functions CG1 2 - 

b735 Muscle tone functions CG1 1 - 

d230 Carrying out daily routine SPG 2 � 

d410 Changing basic body positions CG1 2 � 

d420 Transferring oneself CG1 2 � 

d440 Fine hand use CG1 1 - 

d465 Moving around using equipment CG1 1 � 

d470 Using transportation CG1 2 - 

d520 Caring for body parts CG2 1 � 

d530 Toileting CG2 2 - 

d570 Looking after one’s health CG2 1 � 



4+ 3+ 2+ 1+ 0 1 2 3 4 4+ 3+ 2+ 1+ 0 1 2 3 4 

e115 Assistive products… for personal use in daily living CG2 +4 � 

e120 Assistive products---for personal…mobility … CG1 +4 � 



Keep in mind: 

The ICF Evaluation Display… 

1… depicts the changes in a patient’s functioning 

status and goal achievement 

2… provides information for further rehabilitation 

planning 


Activity and Participation 

d230 Die Carrying tägliche Routine out durchführen daily routine d230 (9) 

Mit d240 Stress Handling u. a. psych. stress Anforderungen and umgehen o. psychol. d240 (5) 


Eine elementare Körperposition wechseln d410 (6) 0% 33% 33% 33% 


Sich verlagern d420 (4) 0% 25% 50% 25% 

d440 Fine hand use 

Feinmotorischer Handgebrauch d440 (2) 0% 50% 50% 0% 


Hand- und Armgebrauch d445 (2) 


Sich auf andere Weise fortbewegen d455 (4) 0% 25% 50% 25% 


Sich unter Verwendung von Geräten fortbewegen d465 (5) 0% 60% 20% 20% 

d470 Using transportation 

Transportmittel benutzen d470 (1) 


Seine Körperteile pflegen d520 (6) 

d530 Toileting 

Die Toilette benutzen d530 (6) 

d550 Eating 

Essen d550 (3) 

d570 Looking after one‘s health 

Auf seine Gesundheit achten d570 (4) 0% 25% 50% 25% 


Elementare interpersonelle Aktivitäten d710 (3) 




Assessment Evaluation 

0% 67% 33% 

0% 80% 20% 

0% 100% 0% 

100% 0% 

0% 67% 33% 

0% 50% 50% 

0% 100% 0% 

0% 100% 0% 

Evaluation 

11% 33% 44% 11% 

0% 20% 60% 20% 

33% 33% 17% 17% 

25% 25% 50% 0% 

50% 0% 50% 0% 

100% 0% 

25% 0% 25% 50% 

20% 40% 40% 0% 

100% 0% 

17% 17% 33% 33% 

17% 17% 33% 33% 

0% 33% 67% 0% 

25% 25% 50% 0% 

0% 33% 67% 0% 

Erholung und Freizeit d920 (3) 0% 100% 0% 

33% 67% 0% 

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 

0=no 1=mild 2=moderate 3=severe 4=complete 

Problem Problem Problem Problem Problem 

(0-4%) (5-24%) (25-49%) (50-95%) (96-100%)


Practicability of the ICF Categorical Profile 

The use of the ICF Categorical Profile 

• facilitated a clear depiction of a patient‘s 

functioning status and allowed the 

documentation of rehabilitation goals and 

intervention targets 

• contributed rehabilitation management by 

increasing communication and common goalsetting 

• increased time consumption for documentation 



Practicability of the ICF Categorical Profile 

Challenges: 

• ICF categories were experienced too less 

comprehensive and specific 

• Definition of ICF categories were experienced 

sometimes too less precise and sometimes 

overlapping 

• Rating within ICF Qualifiers was experienced too 

less objective 

• ICF Qualifiers are too less sensitive for illustrating 

changes in the functioning states 

• Ambivalent EF cannot be coded. 



6. Ausblick 

• Das ICF Modell und Klassifikation (ICF-CY) bieten 

eine umfassende und dynamische Perspektive für 

die Rehabilitation von Kindern und Jugendlichen 

• Weiterentwicklungen in Forschung und Praxis sind 

aber unabdingbar: 

– Noch keine diagnosespezifischen Core Sets für 

Kinder und Jugendliche -> Differentielle Core 

Sets für unterschiedliche Entwicklungsstufen 

– Klinische ICF Tools sind am Anfang ihrer 

Entwicklung und weisen noch einige Schwächen 

auf 

76


6. Ausblick 

• Kaum systematische Evaluationsstudien bzgl. 

clinical effectiveness 

• Mittelfristig muss eine Erhöhung des 

Dokumentationsaufwands durch ICF vermieden 

werden, z.B. 

– die Entwicklung ICF-basierter Outcome Instrumente 

– durch integrierte, elektronische ICF-basierte 

Dokumentationssysteme 

– Algorhythmen zur Umrechnung klinischer 

Testergebnisse in ICF Qualifier 

• Klärung des Verhältnisses zur ICD: 

– Symptome und Functioning? 

– Risk factors und Umweltfaktoren? 

77

Danke für Ihre Aufmerksamkeit! 


78

Training Material der ICF Research Branch 

http://p.ideaday.de/104.2/icf/ 


Ressourcen 


research branch 

The use of the ICF Core Sets in 

clinical practice and research 

Training Video 

ICF Research Branch of WHO CC FIC (DIMDI) 

Swiss Paraplegic Research 

Ludwig-Maximilians-University 

http://www.icf-researchbranch.org/aboutus/services. 

htm 

79

Backup – ICF Linking 


80

3.2. Linking health and health related information to the ICF 

Targets for ICF linking: 

• standardized patient-oriented 

outcomes 

• clinical assessments, also those 

requiring an specialized apparatus 

• interventions targets 

• qualitative data 



Linking steps for qualitative data 

Preparation 

of the information 

Divide the text 

where a change 

in meaning is 

discerned 


Identification 

of linking units 

Linking of linking 

unit to the ICF 

The text contained between two divisions usually have 

a common unifying theme


Data from a qualitative interview: 

“Sometimes I s-s-stutter and can’t find the right 

word to use, but only when I am around strangers 

for the first time. Because of this I have a hard 

time making friends, since they make fun of me, or 

else try to keep their distance. But recently things 

have been looking up for me because my parents 

have gotten me a dog as a new friend and they say 

that as soon as I have my birthday and I turn 11 I 

can take the dog for long walks. Right now, though, 

I feel sad most of the day.” 



Linking steps for qualitative data 

Preparation 

of the information 

Divide the text 

where a change 

in meaning is 

discerned 


Identification 

of linking units 

What is this text 

about? 

(in the peron’s own 

words) 

Linking of linking 

unit to the ICF


Division of text when a 

change in meaning is 

discerned 

Sometimes I s-s-stutter and can’t 

find the right word to use, but only 

when I am around strangers for the 

first time. 

Because of this I have a hard time 

making friends, since they make fun 

of me, or else try to keep their 

distance. 

But recently things have been looking 

up for me because my parents have 

gotten me a dog as a new friend and 

they say that as soon as I have my 

birthday and I turn 11 I can take the 

dog for long walks. 

Right now, though, I feel sad most of 

the day 


Linking unit ICF Code 

-Sometimes I s-s-stutter 

-can’t find the right word to use 

-only when I am around 

strangers for the first time


Is the linking unit an element of …? 

If yes… 

Body function 

and Body structure 

• Which component? 


(disease, trauma) 

Environmental 

factors 

• Which chapter within the selected component is the most appropriated? 

• Which category within the selected chapter is the most precise? 


Activity Participation 

Personal 

factors


Division of text when a 

change in meaning is 

discerned 

Sometimes I s-s-stutter and can’t 

find the right word to use, but only 

when I am around strangers for the 

first time. 

Because of this I have a hard time 

making friends, since they make fun 

of me, or else try to keep their 

distance. 

But recently things have been looking 

up for me because my parents have 

gotten me a dog as a new friend and 

they say that as soon as I have my 

birthday and I turn 11 I can take the 

dog for long walks. 

Right now, though, I feel sad most of 

the day 


Linking unit ICF Code 

-Sometimes I s-s-stutter 

-can’t find the right word to use 

-only when I am around 

strangers for the first time 

-b3300 Fluency of speech 

-b16710 Expression of spoken 

language 

-d730 relating with strangers



Linking Methodology 

Uses and advantages


The health and health-related 

information for linking may be derived 

from: 

• standardized patient-oriented 

outcomes 

• clinical assessments, also those 

requiring an specialized apparatus 

• interventions targets 

• qualitative data 



When a single 

patient-oriented 

measure is linked 

… 

SF-36 

INSTRUCTIONS: This survey asks for 

your views about your health. This 

information will help keep track of how 

you feel and how well you are able to 

do your usual activities. 

Answer every question by marking 

the answer as indicated. If you ar 

unsure about how to answer a 

question, please give the best answer 

you can. 


b1 

b130 

b134 

b152 

b180 

b1801 

b280 

• 

• 

• 

• 

s299 

s710 

s720 

s730 

s73001 

s73011 

• 

• 

• 

• 

• 

• 

• 

• 

d170 

d230 

d360 

d410 

d415 

d430 

• 

• 

• 

• 

• 

e110 

e115 

e120 

e125 

e135 

e150 

• 

• 

1424


… its content validity can be studied 

– breadth of coverage 

– repetition of content area 



The SF-36 addresses: 

b130 3 

b1300 1 

b152 13 

b280 3 

d 9 

d4102 1 

d4105 2 

d4300 1 

d4309 1 

d4500 1 

d4501 1 

d4509 1 

d4551 2 

d540 1 

d589 1 

d640 1 

d859 7 

d9 4 


The SF-36 also addresses: 

gh 15 

nc 7 

pf 4 

ph 10 

d 9


When several 


measures are 

linked … 

MHQ 

DAQ 

Joint mobility 

Mobility (general) 

Muscle power / Strength 

Pain 

Stability Joint of joints mobility 

Emotional Mobility function (general) 

Engergy Muscle & Drive SF-36 power functions / Strength 

Gait / Ambulation 

Pain 

Stiffness Stability of joints 

Muscle Emotional endurance INSTRUCTIONS: 

function 

This survey asks for 

Sexual Engergy functions your 

& 

views 

Drive 

about 

functions 

your health. This 

Sleep Gait / Ambulation SIP 


Stiffness 


Muscle 

do 

endurance 

your usual activities. 

Sexual functions 

Sleep 

Answer every Joint mobility question by marking 

the answer Mobility AIMS 

as indicated. (general) If you ar 

unsure about Muscle how power to answer / Strength a 

question, Pain please give the best answer 

you can. Stability Joint of joints mobility 


Engergy Muscle & Drive HAQ power functions / Strength 


Pain 



function 



& 

views 


about 

functions 


Sleep Gait / 

information 

Ambulation 

will help keep track of how 

Stiffness 


Muscle 

do 

endurance 



Sleep 





you can. 


b1 

b130 

b134 

b152 

b180 

b1801 

b280 

• 

• 

• 

• 

s299 

s710 

s720 

s730 

s73001 

s73011 

• 

• 

• 

• 

• 

• 

• 

• 

d170 

d230 

d360 

d410 

d415 

d430 

• 

• 

• 

• 

• 

e110 

e115 

e120 

e125 

e135 

e150 

• 

• 

1424


… their content can be compared 

and the most appropriate 

measure to address the person’s 

needs can be selected 



When several 


measures are 

linked … 

MHQ 

DAQ 

Joint mobility 

Mobility (general) 

Muscle power / Strength 

Pain 

Stability Joint of joints mobility 


Engergy Muscle & Drive SF-36 power functions / Strength 


Pain 



function 



& 

views 


about 

functions 


Sleep Gait / Ambulation SIP 


Stiffness 


Muscle 

do 

endurance 



Sleep 

Answer every Joint mobility question by marking 

the answer Mobility AIMS 

as indicated. (general) If you ar 

unsure about Muscle how power to answer / Strength a 

question, Pain please give the best answer 

you can. Stability Joint of joints mobility 


Engergy Muscle & Drive HAQ power functions / Strength 


Pain 



function 



& 

views 


about 

functions 


Sleep Gait / 

information 

Ambulation 

will help keep track of how 

Stiffness 


Muscle 

do 

endurance 



Sleep 





you can. 


b1 

b130 

b134 

b152 

b180 

b1801 

b280 

• 

• 

• 

• 

s299 

s710 

s720 

s730 

s73001 

s73011 

• 

• 

• 

• 

• 

• 

• 

• 

d170 

d230 

d360 

d410 

d415 

d430 

• 

• 

• 

• 

• 

e110 

e115 

e120 

e125 

e135 

e150 

• 

• 

1424


… the basis for categories-specific item banks can 

be created 



b130 Energy and drive 

MFI-20 

I feel fit. 

I feel very active. 

I feel tired. 

I am rested. 

Physically, I feel only able to do a little. 

Physically, I can take on a lot. 

Physically, I feel I am in bad condition. 

I tire easily. 

Physically, I feel I am in excellent condition. 

CES-D 

I did not feel like eating; my appetite was poor. 

I felt that everything I did was an effort. 

I could not get “going”. 


RAQOL 

I have to go to bed earlier than I would like to. 

It’s too much effort to go out and see people. 

I have to keep stopping what I am doing, to rest. 

I feel tired whatever I do. 

SF-36 

Did you have a lot of energy? 

Did you feel worn out? 

Did you feel tired?


b130 Energy and drive 

RAQoL 25: It’s too much effort to go out and see people. 

CES-D 20: I could not get “going”. 

CES-D 07: I felt that everything I did was an effort. 

SF-36 9g: Did you feel worn out? 

MFI 2: Physically, I feel only able to do a little. 

SF-36 9e: Did you have a lot of energy? 

MFI 5: I feel tired. 

MFI 3: I feel very active. 

MFI 8: Physically, I can take on a lot. 

MFI 1: I feel fit. 

MFI 12: I am rested. 

MFI 16: I tire easily. 

RAQoL 10: I have to keep stopping what I am doing, to rest. 

SF 36 9i: Did you feel tired? 

RAQoL 21: I feel tired whatever I do. 

MFI 20: Physically, I feel I am in an excellent condition. 

Cieza A, Hilfiker R, Boonen A, Chatterji S, Kostanjsek N, Ustün BT, Stucki G. Items from patient-oriented instruments 

can be integrated into interval scales to operationalize categories of the International Classification of Functioning, 

Disability and Health. J Clin Epidemiol. 2009 Sep;62(9):912-21 


0 10 20 30 40 50 60 70 80 90 100 

Energy and 

drive sum score


The use of the linking methodology in qualitative 

data obtained from patients is useful for: 

• identifying patients’ needs and for comparing 

these needs among different groups of patients 

• evaluating the content validity of instruments 

– Do the existing instruments address what is 

relevant to patients? 

• evaluating interventions and studies 

– Do the existing interventions and the studies 

being performed address what is relevant to 

patients?

Dr. J. Reinhardt - Intern. Klassifikation ICF als übergreifendes Konzept

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