chair for public health and health service research applying the international classification of...

Chair for Public Health and Health Service Research

Applying the International Classification of

Functioning, Disability and Health (ICF)

in Hand Therapy

Alexandra Rauch, PT, MPHChair for Public Health and Health Service Research

Ludwig-Maximilians-University, Munich, Germany25.05.2013

Applying the ICF in hand therapy

• About the ICF

• Development of ICF Core Sets

• The ICF Core Sets for hand conditions – where are we now?

• The ICF Core Sets for hand conditions – what is next

33

Hand conditions

• Wounds• Fractures• Tendon injuries• Ruptures, strains and sprains of

ligaments• Nerv injuries• Amputations• Burns• Allergies• Carpal tunnel syndromes• Complex regional pain syndrome• Rhizarthrosis

Injuries - Diseases

About the ICF

What do these diagnosis tell us about the lived experience of a person

living with a hand condition?

44

ActivitiesBody Functions Body Structures

Participation

About the ICF

Health Condition(disease, trauma)

Environmental Factors

Personal Factors

Functioning - Disability

55

Not able to work as goldsmithDifficulties with riding a bicycleNot able to play piano

• Difficulties to grab and hold big or heavy objects• Difficulties with moving small objects with fingers• Difficulties to lift objects• Difficulties with washing

hair and body• Difficulties with cooking and cleaning the house

• Skin damage (scar)• Reduced sensitivity• Decrased muscle power • Reduced joint movement• Pain


Participation

About the ICF



Personal Factors

Flexor tendon injuryICD 10: S 66.114 weeks ago

52 years old women, living aloneDaughter and little grandchildGoldsmith, owner of jewelry store

No assistive devicesSupport from daughterPhysiotherapy 2/week

66



• Difficulties to grab and hold big or heavy objects• Difficulties with moving small objects with fingers• Difficulties to lift objects• Difficulties with washing

hair and body• Difficulties with cooking and cleaning the house



Personal Factors




77


Participation

About the ICF



Personal Factors

Functioning DisabilityCan we standardize the

information reagarding health

and functioning???Can we standardize the

information reagarding health

and functioning???

88

Joint

use

Family of International Classifications (FIC)

Diseases Functioning/Disability

About the ICF

ICF

ICDHealth condition

Environmental factors Personal factors

Body functionsBody structures

Activities Participation

About the ICF

11Describing Functioning and Disability

b11420 -b51059

s11000 -s76009

b1100 -b7809

s1100 -s8309

d1550 -d9309

e1100 -e5959

b110 -b899

s110 -s899

d110 -d999

e110 -e599

b1 – b8 s1 – b8 d1 – d9 e1 – e5

ICF

Contextual factors

Body functions and Structures

Activities and Participation

Environmental factors

Personal factors

Functioning and Disability

About the ICF

The classification Structure

Chapter 1 MENTAL functions

Chapter 2 SENSORY functions and PAIN

Chapter 3 VOICE and SPEECH functions

Chapter 4 Functions of the CARDIOVASCULAR, HAEMATOLOGICAL, IMMUNOLOGICAL and RESPIRATORY system

Chapter 5 Functions of the DIGESTIVE, METABOLIC and ENDOCRINE system

Chapter 6 GENITOURINARY and REPRODUCTIVE functions

Chapter 7 NEUROMUSCULOSKELETAL and MOVEMENT-RELATED functions

Chapter 8 Functions of the SKIN and RELATED STRUCTURES

Body structures

Body function




About the ICF

Chapter 1 MENTAL functions

Chapter 2 SENSORY functions and PAIN

Chapter 3 VOICE and SPEECH functions

Chapter 4 Functions of the CARDIOVASCULAR, HAEMATOLOGICAL, IMMUNOLOGICAL and RESPIRATORY systems

Chapter 5 Functions of the DIGESTIVE, METABOLIC

and ENDOCRINE SYSTEMS

Chapter 6 GENITOURINARY and REPRODUCTIVE functions


Chapter 8 Functions of the SKIN and RELATED STRUCTURES

Body structures

Body function



About the ICF



Body structures

Body function



b710 Mobility of joint functions

b715 Stability of joint functions

b720 Mobility of bone functions

b730 Muscle power functions

b735 Muscle tone functions

b740 Muscle endurance functions

b750 Motor reflex functions

b755 Involuntary movement reaction functions

b760 Control of voluntary movement functions

b765 Involuntary movement functions

b770 Gait pattern functions

b780 Sensations related to muscles and movement functions

About the ICF


Chapter 7 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED functions

Body structures

Body function




Functions related to the tension present in the resting muscles and the resistance offered when trying to move the muscles passively.

Inclusions: functions associated with the tension of isolated muscles and muscle groups, muscles of one limb, one side of the body and the lower half of the body, muscles of all limbs, muscles of the trunk, and all muscles of the body; impairments such as hypotonia, hypertonia and muscle spasticity

Exclusions: muscle power functions (b730); muscle endurance functions (b740)

About the ICF



Body structures

Body function



310

493

384

253


b7350 Tone of isolated muscles and muscle groupsb7351 Tone of muscles of one limbb7352 Tone of muscles of one side of bodyb7353 Tone of muscles of lower half of bodyb7354 Tone of muscles of all limbsb7355 Tone of muscles of trunkb7356 Tone of all muscles of the body

About the ICF


e135 Products and technology for personal use in daily life

d850 Remunerative employment

d440 Fine hand functions


s730 Structure of the upper extremity

Body structures

Body function



310

493

384

253

specify

About the ICF


Body structures

Body function



310

493

384

253

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

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

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

4 COMPLETE problem (total,...) (96-100%)

0 NO problem (none, absent, negligible,...) (0-4%)

b730.3 = Severe problems in muscle power functions

The classification ICF Qualifier

specify

About the ICF

evaluate

1919


• Difficulties to grab and hold big or heavy objects• Difficulties with moving small objects with fingers• Difficulties to lift objects

• Difficulties with washing hair and body

• Difficulties with cooking and cleaning the house



Personal Factors




• b820.1 Repair functions of the skin

• b265.3 Touch funtions• b730.3 Muscle power functions

• b710.3 Mobility of joint functions

• b280.2 Sensation of pain

• d4401.3 Grasping• d4402.3 Manipulating• d4300.2 Lifting• d5100.2 Washing body• d630.1 Preparing meals

• d6402.2 Cleaning living area

• d850.4 Remunerative employment

• d4750.4 Driving human powered transportation

• d9202.4 Arts and culture

• e1151.4 Assistive products and technology for personal use in daily living

• e310+3 Support from family• e5800+1 Health services

2020


• b820.1 Repair functions of the skin• b265.3 Touch funtions• b730.3 Muscle power functions • b710.3 Mobility of joint functions • b280.2 Sensation of pain• d4401.3 Grasping• d4402.3 Manipulating• d4300.2 Lifting• d5100.2 Washing body• d630.1 Preparing meals• d6402.2 Cleaning living area• d850.4 Remunerative employment • d4750.4 Driving human powered transportation • d9202.4 Arts and culture• e1151.4 Assistive products and technology for personal use in daily living

• e310+3 Support from family• e5800+1 Health services

0 1 2 3 4

Number of ICF categories

ICF Qualifier

Body structures

Body function



310

493

384

253

About the ICF

The classification

Very comprehensive Very comprehensive

Facilitates profiles Reliability?

Body structures

Body function



310

493

384

253

About the ICF

The classification

"To be useful, practical ICF based tools need to be tailored to the need of the users without forgoing the information needed for health statistics and health reporting“

Dr. Bedirhan ÜstünWHO Classification Office Director

Üstün B et.al. Common yet specific tools to measure clinical outcomes: ICF Comprehensive Sets and ICF Core Sets. J Rehab Med 2004; (44 suppl):7-8.

s110s120s130s430s510s710

… b110b114b117b130b152b144b730

...d110d240d410d415d520d630d920

…e110e115e120e125e130e150

…

s110s430s710b110b130b152b730d240d410d415d920e110e120e130

Body structures

Body function



310

493

384

253

Development of ICF Core Sets

Empirical study(Patient data)

Qualitative study(Patient interviews)

Systematic Review(Scientific literature)

Expert Survey(Multiprofessional)

International Consensus-Conference

ICF Core Sets

(Comprehensive and Brief)

TIME

Testing &Validation


Preliminary studies Decision Validation

• Developed from 2008 to 2010

• Applicable in hand injuries and hand diseases

• 117 categories in the Comprehensive ICF Core Set

• 23 categories in the Brief ICF Core Set

The ICF Core Sets for hand conditions – where are we now?

Empirical study(Patient data n=210)

Qualitative study(Patient interviews n=59)

Systematic Review(Scientific literature)

Expert Survey(Multiprofessional n=162

International Consensus-Conference

ICF Core Sets

(Comprehensive and Brief)

Validation of the ICF Core Sets

forHand Conditions

in Germany

2008/2009 05/2009 2010 2012-2015

Preliminary studies Decision Validation Implementation


2828

Brief ICF Core Set for Hand conditions

Body structuress120 Structure of the spinal cord and related structures

s720 Structure of shoulder region

s730 Structure of the upper extremity

Activity and Participationd230 Carry out daily routine

d430 Lifting and carrying objects


d445 Hand and arm use

d5 Self-care

d6 Domestic life

d7 Interpersonal interactions and relationships

d840-d859 Remunerative employment

Body functionsb152 Emotional functions

b265 Touch function

b270 Sensory functions related to temperature and other stimuli

b280 Sensation of pain

b710 Mobility of joint functions

b715 Stability of joint functions


b760 Control of voluntary movement functions

b810 Protective functions of the skin

Environmental factorse1 Products and technology

e3 Support and relationships

e5 Services, systems and policies

2929

Comprehensive ICF Core Set for Hand conditions

Body structuress120 Structure of the spinal cord and related structuress410 Structure of cardiovascular system

s710 Structure of head and neck region

s720 Structure of shoulder region

s730 Structure of the upper extremity s7300 Structure of upper arm

s7301 Structure of forearm

s7302 Structure of hand

s770 Additional musculoskeletal structures related to movement

s810 Structure of areas of skin

s830 Structure of nails

3030


Body functionsb134 Sleep functions

b152 Emotional functions b1801 Body image

b260 Proprioceptive functions

b265 Touch functions

b270 Sensory functions related to temperature and other stimuli b2700 Sensitivity to temperature

b2701 Sensitivity to vibration

b2702 Sensitivity to pressure

b2703 Sensitivity to a noxious stimulus

b280 Sensation of painb415 Blood vessel functions

3131


Body functionsb710 Mobility of joint functions b7100 Mobility of a single joint

b7101 Mobility of several joints

b715 Stability of joint functionsb720 Mobility of bone functions

b730 Muscle power functions b7300 Power of isolated muscles and muscle groups

b7301 Power of muscles of one limb


b740 Muscle endurance functions

b760 Control of voluntary movement functionsb765 Involuntary movement functions

b780 Sensations related to muscles and movement functions

3232


Body functionsb810 Protective functions of the skinb820 Repair functions of the skin

b830 Other functions of the skin

b840 Sensations related to the skin

b860 Functions of nails

3333


Activity and Participationd170 Writing

d230 Carry out daily routined360 Using communcation devices and techniques

d410 Changing basic body positions

d420 Transferring oneself


d440 Fine hand functions d4400 Picking up

d4401 Grasping

d4402 Manipulating

d4403 Releasing

d4408 Fine hand use, other specified

3434


Activity and Participationd445 Hand and arm use d4450 Pulling

d4451 Pushing

d4452 Reaching

d4453 Turning or twisting the hands or arms

d4454 Throwing

d4455 Catching

d4458 Hand and arm use, other specified

d455 Moving around

d465 Moving around using equipment

d470 Using transportation

d475 Driving

3535


Activity and Participationd5 Self-care d510 Washing oneself

d520 Caring for body parts

d530 Toileting

d540 Dressing

d550 Eating

d560 Drinking

d570 Looking after one´s health

d6 Domestic life d620 Acquisition of goods and services

d630 Preparing meals

d640 Doing housework

d650 Caring for household objects

d660 Assisting others

3636


Activity and Participationd7 Interpersonelle Interaktionen und Beziehungend810 – d839 Education

d840-d859 Work and employmentd920 Recreation and leisure

3737


Environmental factorse1 Products and technology e110 Products or substances for personal consumption

e115 Products and technology for personal use in daily living

e120 Products and technology for personal indoor and outdoor mobility and transportation

e125 Products and technology for communication

e130 Products and technology for education

e135 Products and technology for employment

e140 Products and technology for culture, recreation and sport

e150 Design, construction and building products and technology of buildings for public use

e155 Design, construction and building products and technology of buildings for private use

e165 Assets

3838


Environmental factors e225 Climate

e3 Support and relationships e310 Immediate family

e315 Extended family

e320 Friends

e325 Acquaintances, peers, colleagues, neighbours and community members

e330 People in positions of authority

e335 People in subordinate positions

e340 Personal care providers and personal assistants

e345 Strangers

e355 Health professionals

e360 Other professionals

3939


Environmental factors e410 Individual attitudes of immediate family members

e420 Individual attitudes of friends

e425 Individual attitudes of acquaintances, peers, colleagues, neighbours and community members

e430 Individual attitudes of people in positions of authority

e440 Individual attitudes of personal care providers and personal assistants

e445 Individual attitudes of strangers

e450 Individual attitudes of health professionals

e455 Individual attitudes of other professionals

e460 Societal attitudes

e465 Social norms, practices and ideologies

4040


Environmental factorse5 Services, systems and policies e525 Housing services, systems and policies

e530 Utilities services, systems and policies

e535 Communication services, systems and policies

e540 Transportation services, systems and policies

e550 Legal services, systems and policies

e555 Associations and organizational services, systems and policies

e570 Social security services, systems and policies

e575 General social support services, systems and policies

e580 Health services, systems and policies

e585 Education and training services, systems and policies

e590 Labour and employment services, systems and policies


How to implement the ICF Core Sets for hand condition in clinical practice?

ICF Core Sets - Manual for Clinical Practice

Eds: J. Bickenbach, A. Cieza, A. Rauch, G. Stucki

Hogrefe 2012



The ICF Core Sets for hand condition Implementation

1. Select ICF categories from the ICF Core Set for hand conditions

1. Select appropriate measures to assess functioning

1. Coordinate assessment

2. Report on functioning



What to measure?

How to measure?

Who to measure?

What to report?

1. Select ICF categories from the ICF Core Set for hand conditions



What to measure?

Use categories from the Brief ICF Core Set...

... and select additional ICF categories from the

Comprehensive ICF Core Set if necessary

The ICF Core Sets for hand conditions – where are we now?1. Select ICF categories from the ICF Core Set for hand conditions

Brief ICF Core Set Comprehensive ICF Core Set

d230 Carry out daily routine

d360 Using communcation devices and techniques


d440 Fine hand functions d4400 Picking up

d4402 Manipulating


d5 Self-care d510 Washing oneself

d540 Dressing

d6 Domestic life

d7 Interpersonal interactions and relationships

The ICF Core Sets for hand conditions – where are we now?1. Select ICF categories from the ICF Core Set for hand conditions

2. Select appropriate measures to assess functioning



How to measure?

The ICF Core Sets for hand conditions – where are we now?2. Select appropriate measures to assess functioning

Patient-reported questionnaire (DASH) Questioning of the patient (patient history) Clinical examination

Observation of the patientStandardized tests

Technical examination (X-Ray, CT, ENG, etc.)

PRQ= Patient reported questionnaire, PH=Patient history; CE=Clinical examination, TI=Technical investigation

ICF categories Assessment (PRQ/PH/CE/TI)

3 Body structures 14

9 Body functions 25

8 Activities and Participation 25

3 Environmental factors 15


ICF category Source SpecificationPRQ PH CE TI

s120 Structure of the spinal cord and related structures X-Ray, CT, ENG, etc.

s720 Structure of shoulder region ---

s730 Structure of the upper extremity Circumferential

measure, Volumetry / X-Ray, CT, etc.



Body structures

s730 Structure of the upper extremity – Bones

s730 Structure of the upper extremity - Swallowing


Technical investigation (e.g. X-Ray)

Circumferential measure



b152 Emotional functions PHQ-9, GAD-7, IES-R / Questioning

b265 Touch function Ten-Test, Object identi-fication (Moberg Test)

b270 Sensory functions related to temperature and other stimuli 2-Point-Discrimination, Pin-

prick, Cold-Warm-Discrimination

b280 Sensation of pain Numeric Rating Scale

b710 Mobility of joint functions Goniometer, Finger-nail-Table-Distance, Fingertip-Palmar-Distance

b715 Stability of joint functions Stability-Tests

b730 Muscle power functions Dynamometer, Pinch gauge

b760 Control of voluntary movement functions Observation, Purdue

Pegboard Test


Body functions

b265 Touch functions

b280 Sensation of pain



Object identification (Moberg Test)

NRS Scale

Dynamometer



d230 Carry out daily routine Questioning

d430 Lifting and carrying objects Observation, Selected tests from EFC

d440 Fine hand functions DASH items 2, 3 / Pick up Test (Moberg Test)

d445 Hand and arm use Observation, Selected tests from EFC

d5 Self-care DASH items 13, 14, 15

d6 Domestic life DASH items 4, 7, 8, 9

d7 Interpersonal interactions and relationships Questioning

d840-d859 Remunerative employment DASH Work module /

Work profile, EFC



Activities and participation




d5 Self-care

Pick up test (Moberg Test)

DASH items


Evaluation functional capacity


e1 Products and technology Questioning

e3 Support and relationships Questioning

e5 Services, systems and policies Questioning





e1 Products and technology

e3 Support and relationships


Questioning

Questioning

3. Coordinate assessment



Who to measure?

Create intervention table:

The ICF Core Sets for hand conditions – where are we now?3. Coordinate assessment

ICF category Assessment Responsibility

s730 Structure of the upper extremity X-Ray MD

b152 Emotional functions Questioning, PRQ MD, Psychologist

b270 Sensory functions related to temperature and other stimuli

2-Point-Discrimina-tion, Pin-prick, Cold-Warm-Discrimination

MD

b710 Mobility of joint functions Goniometer, Pinch Gauge

PT/OT

d440 Fine hand functions Pick up test PT/OT

e3 Support and relationships Questioning MD

4. Report on functioning



What to report?

The ICF Core Sets for hand conditions – where are we now?4. Report on functioning

www.icf-casestudies.org


http://www.icf-core-sets.org/index.php


The ICF Core Sets for hand conditions – what is next?

90

80

01

02

03

04

05

06

07

01

00

No problem

Complete problem

Fu

nctio

nin

g D

isability

Development of functioning scores

Cieza A et al. The International Classification of Functioning, Disability, and Health could be used to measure functioning. J Clin Epidemiol 2009; 62: 899-911

Grill E et al. Scales could be developed based on simple clinical ratings of ICF Core Set categories. J Clin Epidemiol 2009; 62: 891-898


Which ICF Categories should be included in a functioning score?

b110 Consciousness functionsb210 Seeing functionsb310 Vice functionsb410 Heart functionsb510 Ingestion functionsb610 Urinary excretory functionsb710 Mobility of joint functionsb810 Protective functions of the skin…

Body functions

s110 Structure of brains210 Structure of eye sockets310 Structure of noses410 Structure of cardiovascular systems510 Structure of salivary glandss610 Structure of urinary systems710 Structure of head and neck region s810 Structure of areas of skin…

Body structures

d110 Watchingd210 Undertaking simple tasksd310 Communicating with –receiving – spoken messagesd410 Changing basic body positionsd510 Washing oneselfd610 Acquiring a place to lived710 Basic interpersonal interactionsd810 Informal education…

Activity & Participation

Method


Method: Identify ICF categories that explain functioning!

Example: d525 Defecation functions

Example: What explains functioning in persons with spinal cord injury

= good fitting


Example: d550 Eating= poor fitting


Method: Identify ICF categories that explain functioning!

Example: What explains functioning in persons with spinal cord injury

Functioning score

0 10 20 30 40 50 60 70 80 90 100

DisabilityDisability

Cieza A et al. The International Classification of Functioning, Disability, and Health could be used to measure functioning. J Clin Epidemiol 2009; 62: 899-911


1

0

2

3

4

90

80

01

02

03

04

05

06

07

01

00


„Translate“ assessment results

Cieza A et al. Items from patient-oriented instruments can be integrated into interval scales to operationalize categories of the ICF . J Clin Epidemiol 2009; 62: 912-921

90

80

01

02

03

04

05

06

07

01

00

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

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

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

4 (96-100%) COMPLETE problem (total,...)

0 (0-4%) NO problem (none, absent, negligible,...)


Which ICF Categories should be included in a disability score?

Purpose driven:Ministry level Service provision level Professional level




Body functions

Body structures



7979


•b265.3 Touch funtions• b730.3 Muscle power functions • b710.3 Mobility of joint functions • b280.2 Sensation of pain• d440.3 Fine hand function• d4300.2 Hand and arm use• d630.1 Preparing meals• d850.4 Remunerative employment • d4750.4 Driving human powered transportation

0 1 2 3 4

0 10 20 30 40 50 60 70 80 90 100

FunctioningFunctioning

Purpose:

To monitor service provision

Health condition specific

Selection from health condition specific ICF Core Sets

Service provision level


Body functions


Body structures




8181


• b820.1 Repair functions of the skin• b265.3 Touch funtions• b730.3 Muscle power functions • b710.3 Mobility of joint functions • b280.2 Sensation of pain

• d4401.3 Grasping• d4402.3 Manipulating• d4300.2 Lifting• d5100.2 Washing body• d630.1 Preparing meals• d6402.2 Cleaning living area

• d850.4 Remunerative employment • d4750.4 Driving human powered transportation • d9202.4 Arts and culture

0 1 2 3 4

0 10 20 30 40 50 60 70 80 90 100

Activities and ParticipationActivities and Participation

0 10 20 30 40 50 60 70 80 90 100Body functions and structuresBody functions and structures

Purpose:

To measure functioning in relation to intervention goals

Health condition specific

From health condition specific ICF Core Sets

Professional level

Body functions


Body structures

Body functions


Body structures

Body functions


Body structures

Body functions


Body structures

Body functions


Body structures

Self-care

Mobility

Employment

Social lifeEducation


Thank you very much for your attention!

[email protected]

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