Focus on the ICF. Alexandra Rauch, Reuben Escorpizo, Daniel L. Riddle, Inge Eriks-Hoogland, Gerold Stucki, Alarcos Cieza

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1 Focus on the ICF Using a Case Report of a Patient With Spinal Cord Injury to Illustrate the Application of the International Classification of Functioning, Disability and Health During Multidisciplinary Patient Management Alexandra Rauch, Reuben Escorpizo, Daniel L. Riddle, Inge Eriks-Hoogland, Gerold Stucki, Alarcos Cieza Background and Purpose. Physical therapists require a comprehensive assessment of a patient s functioning status to address multiple problems in patients with severe conditions. The International Classification of Functioning, Disability and Health (ICF) is the universally accepted conceptual model for the description of functioning. Documentation tools have been developed based on ICF Core Sets to be used in multidisciplinary rehabilitation management and specifically by physical therapists. The purposes of this case report are: (1) to apply ICF-based documentation tools to the care of a patient with spinal cord injury and (2) to illustrate the use of ICF-based documentation tools during multidisciplinary patient management. Case Description. The patient was a 22-year-old man with tetraplegia (C2 level) who was 5 months postinjury. The report describes the integration of the ICF-based documentation tools into the patient s examination, evaluation, prognosis, diagnosis, and intervention while he participated in a multidisciplinary rehabilitation program for 2 months. Outcomes. The patient s comprehensive functioning status at the beginning of the program, the rehabilitation goals, the intervention plan, and his improvements in functioning following rehabilitation and the according goal achievement were illustrated with physical therapy specific and multidisciplinary ICF-based documentation tools. Discussion. This case report illustrates how the ICF-based documentation template for physical therapists summarizes all relevant information to aid the physical therapist s patient management and how ICF-based documentation tools for multidisciplinary care complement one another and thus can be used to enhance multidisciplinary patient management. In addition, the ICF assists in clarifying clinician roles as part of a multidisciplinary team. The case report demonstrates that the ICF can be a viable framework both for physical therapy and multidisciplinary management and for clinical documentation. A. Rauch, PT, BSc, is Project Leader, Swiss Paraplegic Research, Nottwil, Switzerland, and Project Scientist, ICF Research Branch, WHO CC FIC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Science (IHRS), Ludwig-Maximilian University, Munich, Germany. R. Escorpizo, PT, DPT, MSc, is Research Scientist, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO CC FIC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Science (IHRS), Ludwig-Maximilian University, Munich, Germany. D.L. Riddle, PT, PhD, FAPTA, is Otto D. Payton Professor, Department of Physical Therapy, Virginia Commonwealth University, Medical College of Virginia Campus, Richmond, Virginia. I. Eriks-Hoogland, MD, is Medical Officer, Swiss Paraplegic Research, Nottwil, Switzerland. G. Stucki, MD, MS, is Professor and Chair, Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland, and at Swiss Paraplegic Research, Nottwil, Switzerland; Director, Swiss Paraplegic Research, Guido A. Zäch Strasse 4, CH-6207 Nottwil, Switzerland; and Director, ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. Address all correspondence to Dr Stucki at: gerold.stucki@paranet.ch. Author information continues on next page. Post a Rapid Response to this article at: ptjournal.apta.org July 2010 Volume 90 Number 7 Physical Therapy f 1039

2 A. Cieza, PhD, MPH, is Senior Scientist, Institute for Health and Rehabilitation Sciences (IHRS), Ludwig-Maximilian University, Munich, Germany; Swiss Paraplegic Research, Nottwil, Switzerland; and ICF Research Branch, WHO FIC CC Germany (DIMDI) at Swiss Paraplegic Research, Nottwil, Switzerland, and at Institute for Health and Rehabilitation Sciences (IHRS), Ludwig Maximilian University, Munich, Germany. [Rauch A, Escorpizo R, Riddle DL, et al. Using a case report of a patient with spinal cord injury to illustrate the application of the International Classification of Functioning, Disability and Health during multidisciplinary patient management. Phys Ther. 2010;90: ] 2010 American Physical Therapy Association In many clinical settings, physical therapy often is one critical part of multidisciplinary rehabilitation programs that aim to enable people with health conditions to achieve and maintain optimal functioning and to encourage full participation of individuals in all aspects of life in their environment. 1,2 Spinal cord injury (SCI) is an example of a condition in which patients are faced with a multitude of health-related problems with respect to body functions (physiological functions of body systems) and body structures (anatomical parts of the body) and to activities (execution of tasks or actions) and participation (involvement in life situations), and environmental factors (physical, social, and attitudinal environment in which people live and conduct their life) 3 often play a key role. When multiple systems are affected, as they are in SCI, multidisciplinary approaches are important for optimal care. 4 To address multiple problems, a comprehensive description of a patient s functioning status is an essential element of sound patient management. 5 The International Classification of Functioning, Disability and Health Available With This Article at ptjournal.apta.org etable 1: Physical Therapist Documentation Template: Complete Version etable 2: International Classification of Functioning, Disability and Health (ICF) Intervention Table: Complete Version Discussion Podcast: See the PTJ Web site for participants. Audio Abstracts Podcast This article was published ahead of print on May 27, 2010, at ptjournal.apta.org. (ICF) 6 is the universally accepted conceptual model for the description of functioning. The ICF refers to functioning as an umbrella term for body functions and body structures and for activities and participation. Functioning and disability are considered to be the result of the interaction between a health condition and personal and environmental factors. As a classification system, the ICF provides a hierarchical organization of descriptors in the form of ICF categories. Thus, the ICF framework offers physical therapists and other rehabilitation professionals a common understanding and a standardized language to describe functioning. 7 With the endorsement of the ICF by the American Physical Therapy Association, 8 physical therapists are now faced with the challenge of concretely translating the use of ICF in their daily clinical practice. To address the needs of users, ICF-based practical tools, including the ICF Core Sets, 9,10 have been developed. The ICF Core Sets provide a list of ICF categories applicable and relevant to specific health conditions. Although Brief ICF Core Sets are developed for single encounters, Comprehensive ICF Core Sets are intended for use in multidisciplinary settings. 11 The ICF Core Sets serve as practical tools for the documentation and as a reference standard for the reporting of functioning. 11 To report the extent of problems in specific ICF categories, ICF qualifiers can be used as a rating scale from 0 to 4, which includes the equivalent percentage values as a reference 6 : 0 no problem (none, absent, negligible) 0% 4% 1 mild problem (slight, low) 5% 24% 2 moderate problem (medium, fair) 25% 49% 1040 f Physical Therapy Volume 90 Number 7 July 2010

3 3 severe problem (high, extreme) 50% 95% 4 complete problem (total) 96% 100% Supplementary to the ICF Core Sets, so-called ICF-based documentation tools have been developed to be used in multidisciplinary rehabilitation management. 12 In addition, an ICF-based documentation template is suggested by Escorpizo et al 13 (see companion perspective article in this issue) to be used specifically by physical therapists. This template is based on the Guide to Physical Therapist Practice 14 (herein referred to as the Guide), the elements of which consist of examination and evaluation of the patient s level of functioning, a description of a diagnosis and prognosis, the generation of a plan of care, intervention, and reexamination. The ICF-based documentation tools for multidisciplinary management and the documentation template for physical therapists can be used to complement each other, to illustrate a patient s functioning status, and to chronicle patient management (Fig. 1). The purposes of this case report are: (1) to apply the ICF-based documentation tools for physical therapy and multidisciplinary teams to the care of a patient with SCI and (2) to illustrate the use of ICF-based documentation tools during the patient s care. These documentation tools were integrated with the patient management elements described in the Guide. The patient had an incomplete cervical SCI, and our description of the multidisciplinary care begins 5 months postinjury. Patient History The patient was a 22-year-old man who had started his career as an online graphic designer. A diving accident resulted in a type II dens fracture of the second cervical vertebra Figure 1. Overview of the use of International Classification of Functioning, Disability and Health (ICF)-based documentation tools in patient management. (C2). He was treated at a local hospital and transported to an SCI center 2 days later. He was admitted to the intensive care unit and initially diagnosed with tetraplegia below C2, classified as AIS (American Spinal Injury Association [ASIA] Impairment Scale 15 ) grade A ( no motor or sensory function is preserved below the level of injury ). Three days postinjury, surgery was performed to stabilize the fracture. A stiff collar was prescribed for the first 6 weeks following the surgery. After the surgery, the patient was admitted to the early postacute inpatient unit of the SCI center, where a multidisciplinary rehabilitation program was initiated. In the first 2 weeks, the patient was completely dependent. He required the use of an artificial ventilator 24 hours a day, received only intravenous nutrition, and was able to move only his eyes and mouth. After 6 weeks, his movement-related functions had improved, and he required artificial ventilation only at night. Over the next several weeks, the patient s neurological and overall functioning continued to improve. Upright positioning and graduated training activities to improve gait patterns could be initiated as tolerated by the patient. Five months after the injury, he was able to stand and to take few steps in the parallel bars. Furthermore, the patient achieved a degree of independence in the areas of self-care, respiration and sphincter management, and mobility. This case report was undertaken 5 months following injury and 2 months before the planned discharge. At this time point, a new examination became necessary to adapt and coordinate the plan of care to account for the patient s improved functioning status that had occurred since the injury. The new examination data were used to coordinate and revise care for the remainder of the patient s stay in the rehabilitation center. Examination The Comprehensive ICF Core Set for SCI in the early postacute context 16 was used as the basis to guide the examination. For the description of July 2010 Volume 90 Number 7 Physical Therapy f 1041

4 Table 1. Physical Therapist Documentation Template a : Selected Codes as Examples Patient s Goal: Independent living in the community Long-term goal (LTG): Resumption of leisure activities Short-term goal (STG): 1: Locomotion 2: Carrying, moving, and handling objects Diagnosis: Spinal cord injury (SCI), AIS grade C Date 5 Months Post-SCI 7 Months Post-SCI Examination Intervention Frequency Re-examination ICF Categories Intervention Targets Need to Examine? Test Test Value Intervention Target, Related to STG/LTG Number? Prognosis (Only for Intervention Targets) Physical Therapy Sessions Will Be Provided 1 or 2 Times Daily Retest Value (Only for Intervention Targets) Goal Achieved? Body Functions b7304 Power of muscles of all limbs Yes Manual muscle testing 15 Jamar dynamometer 17 Fist closing (kg) M. gluteus maximus: 4/4 (left/right) M. gluteus medius: 3/3 M. quadriceps femoris: 5/5 M. tibialis anterior: 5/5 M. triceps surae: 3/3 12.6/14.3(left/right) STG1 Related to neurological recovery Training might increase muscle power functions Strength training with equipment M. gluteus maximus: 4/4 M. gluteus medius: 3/3 M. quadriceps femoris: 5/5 M. tibialis anterior: 5/5 M. triceps surae: 4/4 20.4/20.8 Yes b770 Gait pattern functions Yes Observational gait analysis Hyper-extension of the knee joints Abnormal shifting of the upper body Lack of arm swinging Requires forearm crutches for safety reasons STG1 Walking without forearm crutches for moderate distance (up to 100 m) Gait training inside and outside of the parallel bars Able to walk up to 600 m without abnormal gait patterns Yes Body Structures No Activities and Participation d4104 Standing Yes Observation Needs to hold on to something due to lack of power and coordination STG1 Standing without support Repetitive training of transfers No support necessary anymore Yes d4500 Walking short distances Yes Measurement of walking distance 10 steps with support by parallel bars or forearm crutches STG1 Will walk up to 10 m without support Gait training/outdoor training Able to walk up to 600 m without device Yes Environmental Factors e120 Products and technology for personal indoor and outdoor mobility and transportation Yes Inspection of wheelchair fit Position of backrest, size of cushion not optimal STG1 Will be optimized Assigned to occupational therapist Optimal fit Yes Personal Factors (Pf) Influence Positive Negative Goal orientation/motivation X Acceptance of disease X Evaluation and Overall Prognosis: Main problems in the area of mobility according to abnormal movement caused by neurological impairment decreased exercise tolerance Optimistic prognosis due to expected neurological recovery and facilitating environmental and personal factors Discharge Plan: The patient will be referred to physical therapy and occupational therapy outpatient rehabilitation programs Other Notes: a Refer to companion perspective article by Escorpizo et al 13 in this issue. AIS American Spinal Injury Association [ASIA] Impairment Scale f Physical Therapy Volume 90 Number 7 July 2010

5 the patient s current functioning status, the responsibility to examine specific ICF categories was distributed among the physical therapist and the other rehabilitation team members. Problems experienced by the patient were assessed via interview. Afterward, tests were performed to examine each ICF category. The documentation template for physical therapists was used to document the specific tests, examinations, or observations performed by the physical therapist (Tab. 1) (see etab. 1, available at ptjournal. apta.org, for the complete version of the physical therapist documentation template). In the ICF component of body functions and body structures, the physical therapist identified problems such as reduced b265 Touch functions and b270 Sensory functions related to temperature and other stimuli. The patient also had reduced b7304 Power of muscles of all limbs and increased b7353 Tone of muscles of lower half of the body, indicating spasticity (hypertonicity). The patient s b455 Exercise tolerance was decreased and his b440 Respiration functions showed reduced breathing patterns. Impairments in b280 Sensation of pain and b720 Mobility in joint functions in the right shoulder also were found; both are known as frequent problems in patients following SCI. 17,18 The observation of his b770 Gait patterns showed noticeable problems typical for a lack in muscle power. Together with the problematic b755 Involuntary movement reaction functions and b760 Control of voluntary movements, the latter impairments in body functions were considered to increase the risk for falls. 19 Under the ICF component of activities and participation, the physical therapist identified limitations in all aspects of walking, such as d4501 Walking long distances, d4502 Walking on different surfaces, and d4503 Walking around obstacles. Accordingly, d455 Moving around, presented as difficulties climbing stairs, and d460 Moving around in different locations were reflected in his limitations to ambulate in different environments. Due to these limitations, he still required the use of a wheelchair, particularly for long distances. The patient was able to propel the wheelchair and handle the forearm crutches, as captured by the ICF category d465 Moving around using equipment. Although the patient participated in playing table tennis in a supported standing position and some recreational events, his former activities such as riding a bicycle and jogging under category d920 Recreation and leisure were completely restricted. As part of multidisciplinary care, other health care professionals also examined the patient and documented their results in their specific documentation forms. Evaluation The results of the examinations were evaluated, taking into account problems that were indicated by the patient and identified by each team member after performing specific examination procedures. The evaluation included both the analysis of the test results and the rating of the extent of the problem in each ICF category using the ICF qualifiers. The analyses of the results of the physical therapist s examination were considered to be related to abnormal movement. The patient demonstrated clear limitations or restrictions in mobility, particularly with those activities that require lowerextremity function such as transferring, walking, moving around, and driving. These limitations in mobility were considered to be related to neurological impairments (leading to reduced muscle power, touch, and movement functions, among other impairments) and presumably were due to his impaired respiratory functions and sedentary lifestyle, with limited activity for 5 months since the accident that led to reduced exercise tolerance. These mobility problems appeared to further affect the patient s abilities in recreation and leisure, mainly in sporting activities. Afterward, each ICF category was rated by the responsible team member with an ICF qualifier to provide information to the rehabilitation team and to allow the evaluation of the patient s comprehensive functioning state from a multidisciplinary perspective. The examination result served as the basis for this rating to define this evaluation value. Rating all ICF categories allowed the compilation of the patient s comprehensive functioning state within the ICF Categorical Profile. 12 This profile served as the central information source for the rehabilitation team toward planning the intervention (Fig. 2). In addition to the physical therapist s examination and evaluation, the following information was provided by other team members and was discussed based on the patient s ICF Categorical Profile. The occupational therapist reported moderate limitations in d440 Fine hand functions and d430 Lifting and carrying objects due to impaired sensory and muscle power functions. The category d540 Dressing was rated as having a mild problem because it took him a longer than normal to dress himself. The nurse reported mild impairments in b525 Defecation functions ; however, with regard to d530 Toileting as an activity, the patient was reported to be independent. The vocational counselor rated category d850 Remunerative employment as having moderate problems. At the time of the examination, the patient had already started working part-time as a July 2010 Volume 90 Number 7 Physical Therapy f 1043

6 Figure 2. International Classification of Functioning, Disability and Health (ICF) Categorical Profile. 12 The list includes all ICF categories from the Brief ICF Core Set for spinal cord injury in the early postacute context (marked in bold letters) and additional ICF categories from the Comprehensive ICF Core Set for spinal cord injury in the early postacute context examined by the physical therapist and other health care professionals. Asterisk (*) indicates all ICF categories examined by the physical therapist. ICF qualifiers ranged from 0 (no problem) to 4 (complete problem) in the components of body functions, body structures, and activity and participation and from 4 (complete barrier) to 4 (complete facilitator) in the environmental factors. In personal factors, the positive, neutral, or negative influence on the individual s functioning is marked f Physical Therapy Volume 90 Number 7 July 2010

7 Figure 2. Continued graphic designer for his former employer but within the rehabilitation setting in the center. Information regarding environmental factors was gathered from all health care professionals involved in the patient s care. The patient s family ( e310 Immediate family ) and the rehabilitation team ( e355 Health professionals ) were rated as being supportive. The patient had already received e1201 Assistive products and technology for personal indoor and outdoor mobility and transportation, including a wheelchair and forearm crutches, which served as environmental facilitators. At the personal factors level, ambition and clearly defined personal goals were identified. Based on the patient s comments and his attitude during rehabilitation, he was judged by the rehabilitation team as somebody who has accepted his current situation. The evaluation from the multidisciplinary perspective confirmed the main problem of the patient in the area of mobility. Furthermore, his vocational situation was reported as less problematic because his work demands did not require extensive amounts of movement. The environmental factors were all evaluated as facilitators and thus were evaluated to contribute to the patient s recovery. Diagnosis The ICF Assessment Sheet 12 (Fig. 3) supported the diagnostic process, based on a clinical reasoning process. This form provides an overview of the functioning state from both the patient-identified problems using the patient s words gathered from the routine interview that was guided by the ICF components (upper part of the sheet) and the health professional identified problems described in the ICF codes (lower part of the sheet). With this comprehensive overview, which includes all components of functioning, the identification of the relationship between problems and identified causes was facilitated and was easily illustrated. For example, the hypothesized causes for the patient s experienced problems in locomotion (marked in the upper part of the sheet) could be identified from the list of problems identified by the examinations of the health care professionals (eg, b455.1 Exercise tolerance functions and b770.3 Gait pattern functions ). Afterward, these relationships were illustrated with connecting lines. Based on the findings, the patient s neurological health state was diagnosed as AIS grade C (incomplete SCI, motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle July 2010 Volume 90 Number 7 Physical Therapy f 1045

8 Application of the ICF in Multidisciplinary Patient Management Figure 3. International Classification of Functioning, Disability and Health (ICF) Assessment Sheet.12 The upper part of the ICF Assessment Sheet illustrates the patient s perspective of functioning in all components of the ICF. The lower part the evaluation of results from the health care professional s examinations. Each ICF category is rated within an ICF qualifier from 0 (no problem) to 4 (complete problem) (number behind the dot). In Environmental Factors, a denotes a facilitator. The main problems related to locomotion, experienced by the patient are highlighted within the cycle in the upper part. Causes for these limitations were identified by the health care professionals and marked within a connecting line and later defined as intervention targets. grade less than 3 ), with the possibility of further improvements. Prognosis By considering the improvements in the patient s neurological state and the course of recovery of his functioning state since the injury, and taking into account existing evidence about the relationship between the AIS score and walking recovery,20 the prognosis was favorable. The patient s mobility and ability to walk were expected to im1046 f Physical Therapy Volume 90 prove. The identified environmental and personal factors would contribute to the patient s improvements in functioning. However, a complete neurological and functional recovery by the end of the actual inpatient rehabilitation program seemed to be unlikely because of the extent of spinal cord damage and the remaining length of only 8 weeks of the program. Number 7 Plan of Care Goals were established in terms of the components of the ICF in collaboration with the rehabilitation team and the patient and determined by considering the prognosis (expected neurological improvements and facilitating environmental and personal factors). The patient indicated that his goal was to reintegrate into the community and live independently. The patient s long-term goal (LTG), which was expected to be achieved at the end of the rehabilitajuly 2010

9 tion program, was the resumption of leisure activities (eg, running, riding a bicycle) and to be able to swim and drive his car. Two short-term goals (STGs) were defined. The first shortterm goal (STG1) was to improve locomotion, specifically to be able to walk safely with forearm crutches inside buildings. The second shortterm goal (STG2) was to improve his ability with carrying, handling, and moving objects, specifically to be able to perform independently all hand-related tasks. These goals were entered into the ICF Categorical Profile. Based on the goal setting, intervention targets were selected from the list of ICF categories that were included in the ICF Categorical Profile. To become an intervention target, an ICF category has to have an impact on a goal, has to be modifiable, and has to be relevant for the actual situation. With respect to STG1 (locomotion), the selected intervention targets included the patient s reduced muscle power, his involuntary movement functions, and his impairments in muscle tone functions, gait patterns, and coordination of voluntary movements. The impaired respiration, exercise tolerance, and muscle endurance functions also were identified as factors that contributed to the patient s limited locomotion. Activities such as changing and assuming specific body positions, walking long distances or in different environments, driving, and engaging in sports activities also were selected as intervention targets. Furthermore, the optimization of environmental factor assistive devices (eg, forearm crutches, wheelchair) should contribute to facilitate locomotion. The intervention targets related to STG2 (carrying, handling, and moving objects) are shown in the ICF Categorical Profile (Fig. 2). Notably, there were a number of intervention targets that overlapped with STG1. For each of the STGs and intervention targets, a goal value (again, using the ICF qualifier) that was realistic to be achieved in 8 weeks was defined by the rehabilitation team. The time frame for the achievement of the STGs was according to the patient s planned discharge, when the further steps of his rehabilitation should be decided. Intervention Interventions provided by the physical therapist are presented in the documentation template under the column Intervention Frequency (Tab. 1). The ICF Intervention Table 12 with selected codes as examples is shown in Table 2. To illustrate the complete intervention plan, the ICF Intervention Table 12 (see etab. 2, available at ptjournal. apta.org) contains a comprehensive overview of all interventions and the corresponding health care professionals who would address an intervention target. Given the 2 STGs, the majority of the interventions were assigned to the physical therapist, occupational therapist, and sports therapist, who may have overlapping interventions to a certain extent. A social worker and a certified driving instructor also were part of the team. Nursing assistance was not necessary anymore, except for administering medications. The physical therapist implemented a variety of specific techniques to improve the patient s movementrelated functions. To reduce pain and to increase mobility in the patient s right shoulder, manual therapeutic techniques, including active and passive movement techniques, were applied. To improve the patient s respiratory functions, reflex locomotion (Vojta therapy) 21 was performed. Because general exercise activity is essential in people with SCI, 22 various aspects of general exercise activity were addressed. To increase exercise tolerance, the patient was instructed to perform arm ergometer training. 23 To stimulate and improve muscle power functions, the physical therapist again used reflex locomotion, and the sport therapist instructed and supervised strengthening exercises with equipment. 24 To activate the patient s impaired involuntary movement reaction functions, which increased his risk for falls, 25,26 balance exercises comprising the shifting of the center of gravity were administered by the physical therapist and completed within table tennis training supervised by the sport therapist. Regarding problems with gait, the physical therapist addressed gait patterns and walking within specific exercises inside and outside of the parallel bars, 27 and later on different terrains and around obstacles. In the later phase, sport activities also were incorporated to test the patient for skills that are required in different types of recreational activities that would be essential to contribute to the patient s quality of life. 28 To address the impact of a community environment on gait performances, 29 the patient was assigned to a specific city training performed by the occupational therapist. The assignment of interventions and health care professionals for the STG of handling objects also is shown in the ICF Intervention Table (Tab. 2 and etab. 2). The main responsibility to perform these interventions was assigned to the occupational therapist. Other interventions included in the plan of care were safety driving by a certified instructor and the job arrangement with his former employer with the aid of a vocational counselor. Outcome Over the next weeks of rehabilitation, the patient s functioning continued to improve. Seven months postinjury and shortly before his planned discharge, a re-examination July 2010 Volume 90 Number 7 Physical Therapy f 1047

10 Table 2. International Classification of Functioning, Disability and Health (ICF) Intervention Table 12 : Selected Codes as Examples Intervention Targets ICF Categories Intervention Type Intensity MD Nurse PT SPO OT SW Others Evaluation Goal Value b Value b Body Functions b280 Sensation of pain Manual therapy PT program: 7 /wk, X 2 0 b455 Exercise tolerance functions Ergometer training 4 /wk, X 1 0 b710 Mobility of joint functions Passive and active movement of joints PT program: 7 /wk, X X 2 1 b7304 Power of muscles of all limbs Strength training with equipment 4 /wk, X 2 1 b7305 Power of muscles of the trunk Reflex locomotion (Vojta therapy) 3 /wk, X X 2 1 b7353 Tone of muscles of lower half of the body Medical treatment Daily drug intake X X 1 0 b755 Involuntary movement reaction functions Body balance training on instable surface PT program: 7 /wk, X 2 1 Table tennis 3 /wk, X b770 Gait pattern functions Gait training in parallel bars PT program: 7 /wk, X 3 1 Activity and Participation d4104 Standing Repetitive training of transfers PT program: 7 /wk, X X 2 1 d4154 Maintaining a standing position Body balance training on unstable surface PT program: 7 /wk, X 2 0 Table tennis 3 /wk, X d440 Fine hand function Therapeutic games OT program: 7 /wk, X 3 1 d445 Hand and arm use Therapeutic games OT program: 7 /wk, X X 2 1 d4500 Walking short distances Gait training/outdoor training PT program: 7 /wk, X 3 0 d4501 Walking long distances Walking endurance training 4 /wk, X 3 1 d460 Moving around in different locations Outdoor training (area around center) PT program: 7 /wk, X 3 1 Outdoor training (city training) Once, 5 h X d540 Dressing Assistance and instruction Daily X X 1 0 d850 Remunerative employment Counseling and clarification with former employer Once, 3 h X X 2 1 d920 Recreation and leisure Participation in various sport activities 4 /wk, X 3 1 Swim training 4 /sport program () X Environmental factors e120 Assistive products and technology for personal indoor and outdoor mobility and transportation Optimization of wheelchair 3 /OT program, adaptation and counseling X 3 4 a Intervention targets that were assigned to the physical therapist are marked in bold letters. MD medical doctor, PT physical therapist/physical therapy, SPO sport therapist, OT occupational therapist/ occupational therapy, SW social worker. b ICF qualifiers describe the value of the evaluation based on examination and re-examination and for the goal and range from 0 (no problem) to 4 (complete problem) in the components of body functions (b), body structures (s), and activity and participation (d) and from 4 (complete barrier) to 4 (complete facilitator) in the environmental factors f Physical Therapy Volume 90 Number 7 July 2010

11 Figure 4. International Classification of Functioning, Disability and Health (ICF) Evaluation Display. 12 The list includes all ICF categories that were identified as intervention targets. ICF qualifiers ranged from 0 (no problem) to 4 (complete problem) in the components of body functions (b), body structures (s), and activity and participation (d) and from 4 (complete barrier) to 4 (complete facilitator) in the environmental factors. of his level of functioning in all intervention targets was performed. The results of the physical therapist s reexamination were entered in the documentation template in the column Re-examination (Tab. 1). The changes in the patient s level of functioning were evident. The AIS score improved to AIS grade D ( motor function is preserved below the neurological level, with at least half of the key muscles graded at 3 or better ) and the Spinal Cord Independence Measure score achieved a total of 93 out of 100. With respect to locomotion (STG1), muscle power functions increased partially from grade 3/5 and grade 4/5 to grade 5/5 for many muscles, however, both lower limbs still showed reduced muscle power. The exercise tolerance functions also remained slightly impaired. The patient rated his exercise tolerance on the Borg Rating Scale as 10 out of 100. During the re-examination, the patient s muscle tone function was found to be normal. These improvements appeared to contribute to improved gait pattern and increased control of voluntary movements. The patient was now able to walk independently for up to 15 minutes without assistive devices. However, when he walked outdoors, the use of forearm crutches or a wheelchair was still required to avoid limping caused by muscular exhaustion. Accordingly, he was able to climb only 3 flights of stairs and was unable to run. The interventions that aimed to achieve STG2 (carrying, handling, and moving objects) also appeared to have contributed to his overall functional improvements. The assessment of the range of motion of the patient s right shoulder resulted in an increase in flexion from to degrees. Based on a dynamometer analysis, the patient demonstrated an increase in muscle power functions in both hands of up to 50%. Although this finding may have represented a significant gain, for comparison, it still was less than half of the hand force produced by matched men without July 2010 Volume 90 Number 7 Physical Therapy f 1049

12 SCI. 30 The reduced muscle power and persistent absence of sensation appeared to contribute to difficulty in carrying out some daily tasks such as typing, changing a printer cartridge, or carrying heavy jars. Nevertheless, he reported confidence in many other daily tasks such as holding a cup to drink and preparing simple meals. The re-examination of the patient s LTG (recreation and leisure) resulted in some modest gains. Regarding sport activities, he was now able to ride a bicycle with a small frame on flat areas with no traffic. As stated previously, the results again were rated with the ICF qualifiers to define the final value and entered into the ICF Evaluation Display 12 (Fig. 4) to provide comprehensive information to the team. Discussion Conceptual frameworks help to guide communication and patient care. 7 As described by Rauch et al 12 and by Escorpizo et al 13 (see companion perspective article in this issue), ICF-based documentation tools for multidisciplinary use and specific physical therapist s documentation templates delineating relevant patient- and clinician-derived information have been developed to facilitate the translation of the ICF into patient-oriented and comprehensive management. This case report of a person with traumatic incomplete SCI showed how these ICF tools could be integrated into a systematic approach to patient management, which starts from a comprehensive description of impairments, limitations, and restrictions and progresses to providing the necessary intervention and discharge planning. Furthermore, this case report illustrates the benefit and the challenges of blending of the ICF in the form of ICF Core Sets and the ICF qualifiers and the processes of daily physical therapist practice as contained in the Guide. In the perspective article by Escorpizo et al 13 in this issue, it is suggested that the ICF be integrated with the Guide by using ICF Core Sets to develop a documentation template. This template was meant to facilitate efficiency in clinical documentation by physical therapists while encouraging the application of the ICF. The use of the proposed template will allow physical therapists an ICF-based documentation of their specific patient management. This case report illustrates how the documentation template for physical therapists comprises all relevant information for the physical therapist s patient management by structuring the encounter between the physical therapist and the patient, resulting in the documentation of standard measures by way of the ICF categories within the processes as prescribed in the Guide. This approach aids in the clinical decision-making process and at the same time helps in the identification of appropriate strategies toward positive treatment outcomes. This case report has further illustrated how this template and previously developed ICF-based documentation tools for multidisciplinary care complement one another and thus enhance multidisciplinary patient management. 12 The use of the ICF Core Sets for SCI in the postacute context provided guidance in the examination performed by the whole team. The use of ICF Core Sets can help clinicians in identifying aspects of functioning that need to be assessed in their patients. Furthermore, the use of ICF Core Sets can pave the way for how to standardize documentation and subsequently provide a way for creating meaningful group-level data. As a result of using the ICF Core Set in combination with the rating of the extent of a problem in ICF categories with the ICF qualifiers, a comprehensive profile of the patient s functioning state can be created and provided within the ICF Categorical Profile to all team members. Furthermore, the ICF Categorical Profile clearly illustrates the shared goals and facilitates the determination of intervention targets which are related to the goals. Consideration of patients perspectives of their life situation has always been a cornerstone of patient management. Patient-identified problems are important to develop a hypothesis that later could guide intervention. 31 The ICF Assessment Sheet includes the patient perspective and thereby adds rich information to the ICF categories about the patient s own experience. Furthermore, it supports the diagnostic process by facilitating the identification of hypothesized relationships between problems and their causes, which is an important step in the clinical reasoning process. Both the documentation template and the ICF Intervention Table support the generation of the patient s plan of care. By clearly outlining the intervention targets, they facilitate the assignment of necessary interventions and responsible professionals. Because the ICF Intervention Table is comprehensive, the roles of the physical therapists and other team members are made clear, which is essential to enhance professional working relationships. 32 In consequence, the ICF Intervention Table may help to avoid overlap or redundancy among team members, given a multidisciplinary health care setting. The ICF Evaluation Display illustrates the results and evaluation of the reexamination, which can provide a snapshot of a change in the patient s comprehensive functioning state and thereby contribute to further treatment planning. Beside the benefits, there are challenges that can be 1050 f Physical Therapy Volume 90 Number 7 July 2010

13 foreseen with the use of the ICF and the ICF-based documentation tools. The ICF qualifiers have been used as an aggregate rating scale to rate the extent of a problem in ICF categories based on information gathered within the examination and patient interview. The use of the ICF qualifiers provides generally understandable information; however, it was shown that the interrater reliability is only moderate and requires future operationalization of the ICF categories. 33,34 The development of manuals might contribute to the collection of more reliable information. 11,35 The operationalization of ICF categories by integrating instruments into psychometrically sound ICF category interval scales 36,37 or the construction of new ICF-based clinical measures 38 also could increase reliability in ICF-based descriptions of patients functioning states in the future. The administration burden (ie, feasibility) is another matter for consideration. The development of electronically documentation systems may support the practicability and thereby the acceptance of the use by health care professionals in daily routine. Future research is needed to examine and perhaps re-examine the approach illustrated in this case report on how to best implement the ICF among physical therapy and other rehabilitation therapy clinicians. Invited Commentary and Author Response follow on page All authors provided concept/idea/project design. Ms Rauch, Dr Escorpizo, Dr Riddle, and Dr Cieza provided writing. Ms Rauch provided data collection and analysis. Ms Rauch and Dr Cieza provided project management. Dr Escorpizo, Dr Riddle, Dr Eriks- Hoogland, and Dr Cieza provided consultation (including review of manuscript before submission). The authors thank Franziska Egli and the rehabilitation team of Swiss Paraplegic Center for their invaluable support to this project. This article was received October 6, 2009, and was accepted April 12, DOI: /ptj References 1 Stucki G, Cieza A, Melvin J. The International Classification of Functioning, Disability and Health (ICF): a unifying model for the conceptual description of the rehabilitation strategy. J Rehabil Med. 2007; 39: Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81: Biering-Sorensen F, Scheuringer M, Baumberger M, et al. Developing core sets for persons with spinal cord injuries based on the International Classification of Functioning, Disability and Health as a way to specify functioning. Spinal Cord. 2006;44: Kirshblum SC, Priebe MM, Ho CH, et al. Spinal cord injury medicine, 3: rehabilitation phase after acute spinal cord injury. Arch Phys Med Rehabil. 2007;88:S62 S70. 5 Cieza A, Stucki G. Understanding functioning, disability, and health in rheumatoid arthritis: the basis for rehabilitation care. 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14 31 Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003;83: Tempest S, McIntyre A. Using the ICF to clarify team roles and demonstrate clinical reasoning in stroke rehabilitation. Disabil Rehabil. 2006;28: Grill E, Mansmann U, Cieza A, Stucki G. Assessing observer agreement when describing and classifying functioning with the International Classification of Functioning, Disability and Health. J Rehabil Med. 2007;39: Starrost K, Geyh S, Trautwein A, et al. Interrater reliability of the extended ICF core set for stroke applied by physical therapists. Phys Ther. 2008;88: Reed G, Lux J, Bufka L, et al. Operationalizing the International Classification of Functioning, Disability and Health in clinical settings. Rehabil Psychol. 2005; 50: Grill E, Stucki G. Scales could be developed based on simple clinical ratings of International Classification of Functioning, Disability and Health Core Set categories. J Clin Epidemiol. 2009;62: Cieza A, Hilfiker R, Boonen A, et al. 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;62: , 921.e Cieza A, Hilfiker R, Chatterji S, et al. The International Classification of Functioning, Disability and Health could be used to measure functioning. J Clin Epidemiol. 2009;62: f Physical Therapy Volume 90 Number 7 July 2010