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93.3 - An evaluation of 20 year WHO-ICIDH and ICF-based activities by Visio Looijestijn P.1 1Royal Visio, National Foundation for the Visually Impaired and Blind, Research & Development, Haren, Netherlands In 1980 the WHO published the International Classification of Impairments, Disabilities and Handicaps (ICIDH) for classification of the result of diseases and disorders. In 1993 a revision process was started, which resulted in the publication of the International Classification of Functioning, disability and health (ICF) in 2001. According to the ICF model, rehabilitation of people with visual impairments requires insight into the relations between visual diseases and disorders, intact and impaired visual function, visual abilities and disabilities, activities, participation and the environmental factors. Based on that insight the focus of the rehabilitation process can shift from medical causes to optimal participation in daily life. In the last 20 years Royal Visio, National Foundation for the Visually Impaired and Blind in the Netherlands, has worked on the practical implementation of the ICF model in the field of rehabilitation of visually impaired people. During this period, several modifications and additions to the ICF model itself and the adaptation of the rehabilitation methods used in Visio were made. First, classifications of visual impairments needed to be specified and added to the ICF model. Second, the focus of rehabilitation needed to be described in terms of practical participation goals of the patient. Third, diagnostic methods and instruments were developed to assess low and high visual functions, vision related activities and quality of life. Scientific foundations for the modification and adaptation of the ICF model were provided by research projects and dissertations in cooperation with the universities of Groningen, Utrecht and Amsterdam. Since 1993 Visio has published about these developments, for instance on the Vision conferences. This has resulted in a new working definition of low vision in our organisation and for eligibility for services for people with visual disabilities in the Netherlands. These are not only based on medical cause, acuity and visual field, but also on the degree of visual disabilities and participation problems. As a result, people with cerebral visual dysfunctions as well as people with ocular visual dysfunctions have access to rehabilitation.

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Proceedings of the 9th International Conference on Low Vision, Vision 2008, Montreal, Quebec, Canada

July 7 – 11, 2008

An Evaluation of 20 Years WHO-ICIDH and ICF-based activities by Royal Visio

Paul Looijestijn, PhD *

Royal Visio, National Foundation for the Visually Impaired and Blind Department of Research & Development, Haren, the Netherlands

Abstract. In rehabilitation centres for visually impaired and blind people the need for a common, conceptual framework was felt by those in various disciplines working there. Based on the classifications of the WHO (ICIDH and ICF) Visio developed in the last 20 years an interdisciplinary model for the rehabilitation to an optimal participation of visually impaired and blind people (IRM). A method for combining professional judgements with judgments of the client, a new working definition of low vision, instruments for assessment and observation are developed under the umbrella term Visual Profile. The visual profile makes it possible to gain insight into the client’s visual problems from all perspectives: disease, disorder, body function and structure, activities, participation, environmental factors, all of which aids in drawing up an interdisciplinary rehabilitation plan. As a result, people with cerebral visual dysfunctions as well as people with ocular visual dysfunctions have access to rehabilitation. Keywords: WHO; ICIDH; ICF; participation; www.visualprofile.info 1. WHO: ICIDH & ICF

In 1980 the WHO published the International Classification of Impairments, Disabilities and Handicaps (ICIDH) for classification of the result of diseases and disorders [33]. In 1993 a revision process was started which resulted in the publication of the International Classification of Functioning, disability and health (ICF) in 2001 (see figure 1) [34]. In 2007 the WHO published the children and youth version (ICF-CY) [35].

Health Condition Health Condition ((disorder/diseasedisorder/disease))

Interaction of ConceptsInteraction of ConceptsICF 2001ICF 2001

Environmental Environmental FactorsFactors

Personal Personal FactorsFactors

Body Body function&structure function&structure

(Impairment(Impairment))

ActivitiesActivities(Limitation)(Limitation)

ParticipationParticipation(Restriction)(Restriction)

Fig. 1. The WHO-ICF model of functioning and disability: Interactions between the components of ICF. According to the ICF model, rehabilitation of people with visual impairments requires insight into the

relations between visual diseases and disorders, intact and impaired visual function, visual abilities and

* Paul Looijestijn : paullooijestijn@visio.org Visio Noord Nederland, Postbus 144, 9750 AC Haren, the Netherlands.

disabilities, activities, participation and the environmental factors. Based on that insight the focus of the rehabilitation process can shift from medical causes to optimal participation in daily life. 2. ICIDH and ICF-based activities Visio

In the last 20 years Royal Visio, National Foundation for the Visually Impaired and Blind in the Netherlands, has worked on the practical implementation of the ICIDH and later the ICF model in the field of rehabilitation of visually impaired and blind people. During this period, several modifications and additions to the ICF model itself and the adaptation of the rehabilitation methods used in Visio were made. These developments in our organisation are related to national and international developments elsewhere [30;3].

2.1 Classification of visual impairments

First, classifications of visual impairments needed to be specified, added to the ICF model as well as

rehabilitation services [29; 6; 12]. The anatomical structures of eyes, ocular muscles, nerves and tracts and those parts of the brain which are involved in visual processing (dorsal and ventral stream) are important for ocular and/or cerebral diseases or disorders of the visual system (see figure 2: part 4a and 4b). Visual impairments can be found in two types of lower visual functions: the oculomotor and the visual sensory functions (acuity, field, contrast, colour, light adaptation, glare etc.). But also in two types of higher visual functions: the visual-perceptual-cognitive (visual attention, visual spatial relationship and object recognition etc.) and the visual motor functions (eye-hand, eye-foot, eye-body) (see figure 2: part 3). In our opinion a distinction must be made between the visual activities and self-sufficiency of activities in all life areas (see figure 2: part 2). Vision can be an element in every activity in every life area.

This ICF-based approach to low vision is as an element included in the whole process of rehabilitation [32;8;7]. This process of rehabilitation includes so-called moments of convergence (interdisciplinary consultation, common language) and moments of divergence (every care provider works with and for the client at specific goals using their specific methods of assessments and treatment of there own discipline).

4.a Ophthalmological and/or neurological disease/disorder of the visual system : D

Eyes, ocular muscles, nerves/tracts, brain

4.b Anatomical structuresof the visual system: s

3. And/orLower visual functions: b1

OculomotorVisual sensory

And/or:Higher visual functions: b2Visual perceptual-cognitive

Visual motor

2. Activities in all life areas:

a 1 Visual activities

a 2 Self-sufficiency

1. Participation inall life areas:

p 1

5.a Environmental factors: e 5.b Personal factors

= visual related and other variables= visual variables

Fig. 2. Selection, modification and addition of the ICF model to the basic elements of the Visual Profile.

2.2 Determining the focus of rehabilitation Second, the focus of rehabilitation needed to be described in terms of daily life and practical participation

goals of the client. For this the method of a visual profile is developed to gain insight into the relationships between the elements of figure 2 where there are 6 parts in the assessment segment of the process of rehabilitation [15;16;17;18;21]: A) collect and order data in the basic elements of the Visual Profile B) translate and understand all this data C) combine all the data and deduce hypotheses D) check those hypotheses E) explain the clients needs and F) determine goals and actions. In part E and F the answers on 8 questions leads to a rehabilitation diagnosis. The first 5 questions (part E) correspond with the 5 parts (shown in figure 2):

1. Are there restrictions or problems in participation and can we expect them? 2. Is there a relation with limitations in self-sufficiency and visual activities? 3. Is there a relation with visual impairments?

4. Is there a relation with diseases and disorders of the visual system? 5. In which way is there a relation with environmental and personal factors? The other three questions involved in part F are: 6. Is this a treatment for rehabilitation of visually impaired people or for other services? 7. What are the priorities in the participation needs of the client and in which area(s) of daily life? 8. Which actions in each which part in figure 2 can contribute to optimal participation of the client?

2.3 Development of assessment methods and instruments to assess visual function Third, assessments and instruments were developed to assess visual functions, vision related activities and

participation which correspond to the main ICF-classifications of functioning. In 1988 Aart Kooijman, Gerjan van der Wildt a.o. started in the rehabilitation centres of Visio with the assessment of lower visual functions [10], in 1989 this author and Anja van der Wege started the assessment of higher visual functions (part 3 in figure 2) as well as ocular visual impairment [18;22] and cerebral visual impairment [20;28], with a rehabilitation program for parents (figure 2: parts 1, 2 and 3) [13]. In 1994 light adaptation in daily life (figure 2: part 5.a) [4] and observation of visual activities (figure 2: part 2) [14] were included. Included in 1995 were assimilation in and adaptation of the Bayley scales of infant development [26;27;31], in which the “observation list Visual Profile” (figure 2: part 2.a 1) has been an example for other observation lists [5]. Finally, in 2004 a standardized interview of visual activities, self-sufficiency and participation to collect the judgments of the informant (figure 2: parts 1 and 2 for the person with visual impairments and part 5.a for other informants) were added [1;2;18;21].

Scientific foundations for the modification and adaptation of the ICF model were provided by research projects and dissertations in cooperation with the universities of Groningen, Utrecht and Amsterdam[4;18;11]. The classification, methods and instruments are part of the in-service training in our organisation since 1993 and the others in the Netherlands and Flanders [15;16;17]

Since Vision 1993 in Groningen, Visio has published about these developments, for instance on the Vision conferences [32;29;6;13;9;22;23;24;25]. This has resulted in a new working definition of low vision in our organisation and for eligibility for services for people with visual disabilities in the Netherlands [14;18;19]. A person with low vision experienced limitations (disabilities) in visual activities as a result of measured visual impairments (4 groups of functions), which can result in participation problems. These approaches are based on the main ICF-classifications of functioning: body function and structure, activities, and participation. It is not only based on medical causes, acuity and visual field, but also on the degree of visual (dis)abilities and participation possibilities as well as problems. As a result, people with cerebral visual dysfunctions as well as people with ocular visual dysfunctions have access to rehabilitation, assessment when the limitations in visual activities can be the result of visual impairments, and also for treatment when the assessments of visual functions in all 4 groups (if necessary) confirm the visual impairment(s). 3. New parts

The ICF-based developments in our organisation are still going on. In cooperation with the other Dutch organisations for services to visually impaired and blind people, Sensis and Bartiméus, and with a grant of the Dutch foundation ZonMw (InZicht programme), we are building a website with a forum for a worldwide exchange of information about ICF-based contributions to the rehabilitation of people with visual impairments (www.visualprofile.info – see abstract 469). We have taken the initiative for an ICF advisory-board in our new organisation: “Visio-Sensis-de Brink groep”. In cooperation with the University of Groningen we are planning further research. References

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