Use of the International Classification of Functioning, Disability and Health in Brain Injury Rehabilitation

In 1887 a book titled “The International Language” was published by Dr. Ludwig Zamenhof in Warsaw. In the introductory part the famous inventor of Esperanto stated: “How much time, labour, and money are wasted in translating the literary productions of one nation into the language of another, and yet, if we rely on translations alone, we can only become acquainted with a tiny part of foreign literature. If an international language existed, all the translations would have been made into it alone, as into a tongue intelligible to everybody, and works of an international character would be written directly in it. The Chinese wall dividing literatures would disappear, and the works of other nations would be as readily intelligible to us as those of our own authors. Books being the same for everyone, education, ideals, convictions, aims, would be the same too” (Zamenhof, 1887). Decades after with the development of rehabilitation medicine as an independent discipline it turned out that it faced virtually the same problems and hopes: “Chinese walls” in the communication among professionals of different specialties involved in rehabilitation of the same person, the possibility to “become acquainted with a tiny part of foreign literature” due to the language barriers and different national standards in different countries and even within the same country. All this resulting in “much time, labour, and money wasted” that could have been used more efficiently for a good cause of the patient. The situation changed in 2001 with the unanimous approval by the World Health Assembly of the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001). The main purpose of the classification is exactly to provide a common language for professionals working in health-related areas and establish an international standard for description of health-related states including brain injury rehabilitation. The ICF model and classification are briefly introduced below.


Introduction
In 1887 a book titled "The International Language" was published by Dr. Ludwig Zamenhof in Warsaw.In the introductory part the famous inventor of Esperanto stated: "How much time, labour, and money are wasted in translating the literary productions of one nation into the language of another, and yet, if we rely on translations alone, we can only become acquainted with a tiny part of foreign literature.If an international language existed, all the translations would have been made into it alone, as into a tongue intelligible to everybody, and works of an international character would be written directly in it.The Chinese wall dividing literatures would disappear, and the works of other nations would be as readily intelligible to us as those of our own authors.Books being the same for everyone, education, ideals, convictions, aims, would be the same too" (Zamenhof, 1887).Decades after with the development of rehabilitation medicine as an independent discipline it turned out that it faced virtually the same problems and hopes: "Chinese walls" in the communication among professionals of different specialties involved in rehabilitation of the same person, the possibility to "become acquainted with a tiny part of foreign literature" due to the language barriers and different national standards in different countries and even within the same country.All this resulting in "much time, labour, and money wasted" that could have been used more efficiently for a good cause of the patient.The situation changed in 2001 with the unanimous approval by the World Health Assembly of the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001).The main purpose of the classification is exactly to provide a common language for professionals working in health-related areas and establish an international standard for description of health-related states including brain injury rehabilitation.The ICF model and classification are briefly introduced below.

The integrative model of functioning, disability and health
The ICF is a comprehensive classification of health-related domains containing 1424 categories that can exhaustively describe the functional status of a person or simply functioning.WHO proposed to use the term functioning when referring to the real impact of a health condition on the day to day life of a person.When the term "health" can be model they are not yet classified.In all other components, chapters represent the 1 st level of the classification which is the broadest.Each chapter is subdivided into the specific elements of the classification, called categories, which are also organized in a hierarchical structure of 2 nd , 3 rd or 4 th levels.For all categories, except those in body structures, definitions with inclusion and exclusion criteria are provided as shown in the following example: The definitions and inclusion criteria provided for each category give a detailed description of the meaning of the category and help practitioners to correctly use the ICF codes.The exclusion criteria help to differentiate among related and seemingly similar ICF categories.ICF codes are composed of a prefix (b for body functions, s for body structure, d for activity and participation, and e for environmental factors) followed by a numeric code that consists of one digit for the first or chapter level, three digits for the second, four for the third, and five for the fourth level (see example below).The hierarchical organization of the classification allows users to choose a broader (e.g. by using a 1 st level chapter or a 2 nd level category) or a more specific (e.g. by using a 3 rd or 4 th level category) description of an aspect of functioning.The level of specificity increases with each level as it is shown in the above example.The hierarchical organization allows users to choose the level of specificity that is required for the description of functioning for their purpose and information need.Although personal factors are not classified, users may assess and describe them in a manner that is suitable for their purposes.

ICF qualifiers
ICF qualifiers allow to describe the extent of a problem in functioning (impairment, limitation, restriction) and the impact of the environment on functioning and disability.To be meaningful, an ICF code requires at least one qualifier.Hence, a complete ICF code (composed of the letter and numeric code) is completed by at least the first qualifier placed after a dot following the numeric code, e.g.b280.3.For all components (body functions, body structures, activities and participation and environmental factors), the description of the extent of a problem uses the following generic scale: A different number of qualifiers is available for each of the four component (see Table 1).While there is only one qualifier (extent of impairment) for Body Functions, Body Structures may be denoted with three qualifiers (first qualifier = extent of impairment, second qualifier = nature of impairment, third qualifier = location of impairment).For example, the ICF code s7302.412describes a complete impairment (4) due to total absence (1) of the left (2) hand (s7302).For Activities and Participation, two qualifiers are used.The first qualifier is to describe performance, the second qualifier to describe capacity.Performance is understood as what an individual actually does in his or her current environment in light of the positive or negative impact of the environmental factors (including all aspects of the physical, social and attitudinal environment).Capacity, by contrast, describes an individual's intrinsic ability to perform a task or an action independently of the impact of the environment, including the particular personal assistance or assistive devices.Hence, when describing both performance and capacity for the same category the difference between them reflects the extent of the impact of environmental factors on an individual's functional state resulting in the experienced level of disability.For example, the ICF code d450.04 describes a person whose ability to walk is completely impaired (4 = complete problem in capacity) but totally compensated by a prosthesis which is reflected with no limitations in walking in the performance (0 = no problem with performance).Environmental factors are quantified by only one qualifier.However, the impact on the level of disability can be positive (facilitator) or negative (barrier).To denote this, a facilitator is marked with a plus sign instead the dot (+X) and a barrier follows the dot (.X), as in the following examples: e310+2 (= Moderate facilitator 'Immediate family'), e310.2 (=Moderate barrier 'Immediate family').Qualifiers complement an ICF code and provide the complete description of a person's level of functioning or disability.If assessment instruments or other standards are used to measure the level of disability of a specific aspect of functioning, the results of such measurement can be 'translated' into a qualifier.Using qualifiers for the description of disability facilitates a common understanding of the description of a person's level of disability.Furthermore, the use of qualifiers makes it possible to develop functioning profile of a patient.

ICF core sets
With its 1424 categories, the ICF is an exhaustive classification.It allows to create a very detailed and highly individualized functional profile of a person when used as a whole.However, with exhaustiveness can be associated complexity and in some cases even impracticability.ICF is often considered too comprehensive and too complicated for daily practice.The obvious requirement of practicability was the primary reason for the WHO to develop user-friendly tools that would include a purpose-tailored selection of the ICF categories relevant for describing functioning and disability in various contexts related to health conditions (Stucki et al., 2008).These tools are called ICF Core Sets.An ICF Core Set is a selection of categories from the full ICF that correspond to a health condition as coded by the ICD or a particular purpose.There are two main types of the ICF Core Sets, namely, Comprehensive ICF Core Set and Brief ICF Core set.The Comprehensive ICF Core Set includes categories that reflect the whole spectrum of typical problems a patient may face.The Comprehensive ICF Core Set can guide practitioners through the assessment and helps to avoid overlooking aspects of functioning that are likely to present a problem in a patient.Due to its comprehensive amount of categories it is a tool that allows a thorough and multidisciplinary assessment of functioning of a person with a health

ICF in brain injury rehabilitation. An overview
From the ICF perspective, rehabilitation medicine can be defined as the interdisciplinary management of a person's functioning and health.Rehabilitation therefore aims to enable people experiencing or likely to experience disability to achieve and maintain optimal functioning.At the same time, functioning is not considered as the consequence of a disease, but rather as the human experience that is the result of the dynamic interaction between a health condition and both personal and environmental factors (contextual factors).Assessment of functioning is the starting point of a patient and goal oriented, evidencebased and iterative rehabilitation process (Stucki et al., 2007).
The ICF as a conceptual model and ICF-based tools, such as ICF Core Sets, as practical instruments may contribute to a more holistic and structured description of functioning of persons after brain injury (BI).For example, the current data indicate that ICF can be useful in classifying the currently used assessment scales in traumatic brain injury (Cameron et al., 2009).It also allows a standardised and comprehensive analysis of health and health-related consequences, fully applicable to the rehabilitation after BI.Particularly in the area of neurorehabilitation, it may contribute to the evaluation of deficits and identification of treatment goals and targets for intervention (Bilbao et al., 2003).A special additional value of the ICF is seen in its capacity to describe and categorise the environmental factors relevant for rehabilitation (Fries et al., 2008).The rehabilitation programmes designed for patients with BI have to include assessment and treatment of the contextual factors and there is a need for development of the instruments that can quantify these factors.The information about functioning collected using the ICF could be also used to identify needs, match patients to interventions, track functioning over time, measure clinical outcomes and monitor treatment effectiveness.
The applicability of the ICF in brain injured patients was explored in at least fourteen articles published from 2002 to 2010.One article from 2003 generally discusses the applicability of the ICF model to brain injury concluding that it is a potentially useful tool to adequately classify and assess functioning and disability, related to TBI.Two articles are related to the development of the ICF Core Set for traumatic brain injury (TBI) discussing the need for having a practical ICF-based tool to describe functioning of TBI patients which would at the same time allow clinicians to adopt a comprehensive and holistic approach.
The Italian clinical perspective on the potential of ICF core set for TBI argues that ICF makes it possible to describe in a systematic way not only body functions and structures, but also the activities and participation and the influence of the environmental factors.Another study tested the applicability of the ICF checklist for the description of patients with TBI.
The authors concluded that although the checklist can be practical for clinical work, an ICF core set for TBI would be more adequate.Two other articles discuss the application of the ICF model for treatment of communication and cognitive disorders following the TBI.Larkins suggests that the ICF supports a systematic approach for understanding cognitivecommunication disorders in persons with TBI and presents an example of the application of the ICF in such patients.Worral and associates, however, point out that the WHO classification scheme simplifies the real-life communication and can be more useful for a generic description of communicational functioning rather than a individualized one.One study analyzed the possible benefits of the ICF for the description of functioning of returning war veterans who frequently suffer from the consequences of a traumatic brain injury.The author argues that ICF can help to refine the understanding of the challenges the veterans have to confront after coming back.This can assist in making more appropriate decisions for allocation of resources, and for the development and implementation of therapies and rehabilitation interventions.One study summarized the available evidence on the use of the ICF to describe the functioning of severely brain injured persons and concluded that in light of available evidence, the ICF is a useful tool that describes the functioning and needs of patients with TBI.The authors point out that a wider utilization of the ICF can help to allocate resources in order to reach the improvement of the quality of life of patients with TBI.Quality of life is also a concern in another article by Pierce and Hanks.They tested whether the description of functioning based on the ICF can predict life satisfaction, concluding that a combination of ICF components and demographic factors significantly predicted life satisfaction.The study performed by Ehrenfors and associates examined the widely used assessment instruments for description of functioning of schoolaged children with traumatic brain injury through the ICF lens.In their opinion widely used assessment instruments do not cover essential aspects of functioning and disability.An ICFbased questionnaire was developed for TBI patients by a group of Dutch researchers to assess activities and participation (Ptyushkin et al., 2010).
An important additional value of the ICF is seen in its capacity to describe and categorize environmental factors relevant for rehabilitation.Current rehabilitation programs designed for patients with TBI, it has been suggested, have to include assessment and response to contextual factors and there is a need for the development of instruments that can quantify these factors.The role of the ICF in this conceptual shift is discussed.Finally, Whyte suggests that the direction brain injury research will take depends on a variety of factors and is guided in part by underlying theory and in part depends on the location of the target of treatment and how it is classified in the ICF.Recent data also indicate that ICF can be useful in classifying the currently used assessment scales for traumatic brain injury (Whyte, 2009).

Linking medical records of a patient with brain injury to the ICF. A case study
ICF allows to create individual functional profiles of persons with any health condition.Such profiles can be especially valuable when dealing with the complicated and multifaceted health conditions like brain injury.Depending on the purpose when applying ICF in brain injury rehabilitation one can create an ICF profile of a patient either from the start or by linking the already existing medical records to the ICF.An example of the latter is presented below (Ptyushkin et al., 2009).Medical records of a patient after brain injury caused by a traffic accident that took place in April, 2008, who was admitted to the University Rehabilitation Institute (URI) of the Republic of Slovenia in July, 2008, were linked to the ICF.The patient was male, 31 years old at the time of admission, and his Glasgow Coma Scale score after the accident was 6.He was admitted to our Institute after the acute treatment with 8 different diagnoses, all of them corresponding to the ICD section "S" ("Injury, poisoning and certain other consequences of external causes").Information about functioning at admission and discharge was entered separately.Medical records comprised the admission and discharge form and the reports from physiotherapist, occupational therapist, speech therapist and psychologist.
The medical records, which were mostly in text format, were linked to the ICF using the socalled linking rules.The process was divided into the following stages:  identification of the meaning unit -a short phrase or sentence that describes one concrete aspect of functioning;  linking of the meaning unit to the ICF code; and  selection of the appropriate qualifier.An example of the linking process is shown in Table 3.Additionally, the Functional Independence Measure (FIM), which had been previously linked to the ICF by a group of experts at the level of code in the current study (4,5,6), was linked to the level of qualifier.The correspondence of the FIM scores to the ICF qualifiers is presented in Table 4.For practical purposes, it was assumed that the higher level of dependence by FIM, the higher the level of the problem.

Source
Report from psychologist

Meaning unit
…"marked decrease in attention"…

Correspondent ICF Code b140 Attention functions
Correspondent qualifier 3 (serious problem -"marked") Obtained ICF-based functional profile of a patient is presented in Table 5.The profile describes functioning of the patient at the admission and at the discharge.The majority of functional problems of a patient at the level of "body functions" were found in the domains of mental functions and movement-related functions.Within the list of "activities and participation", the patient experienced more difficulties with acquiring skills, communication and activities, related to mobility and self-care.Several relevant environmental factors were identified as well.
In this particular example ICF did not provide any additional information about functioning of a patient, as all the information was taken from the existing medical records.Nevertheless, ICF provided structure to the large amount of diverse information and gave a clear, easy and holistic view of all the different aspects of functioning reflected in different reports and documents.This case study also demonstrates some weak points of the medical documentation.For example, almost no information was found in the medical records regarding activities, related to the daily life (chapter 6 -Domestic life, which includes preparing meals, caring for  household objects, doing housework etc.), interpersonal interactions and relationships, major life areas (which include education, work and employment, and economic life) and community, social and civic life (which includes recreation and leisure, religion and spirituality).
Little information was also found concerning the relevant environmental factors.Those that were identified correspond to "products and technology for daily use" and "support and relationships".Health professionals and "health services, systems and policies" were also found to be the facilitating environmental factors.Rehabilitation had a positive influence mostly on functions of language and memory and activities that are related to mobility and self-care.Some of these are difficult to assess in a rehabilitation hospital, since the patient has to stay at home for some time in order to comprehend the extent of problems with these activities.The impact of the environment is also difficult to assess before the patient has been living at home for a while.Before finishing the rehabilitation, patients usually go home for a weekend to face the reality.After such visits, clinicians should describe the problems that the patients had at home better and be able to suggest feasible solutions.The later should also be written in the medical records.Many areas could not be assessed specifically.The qualifier "8" (standing for "not specified") was used due to the fact that particular aspects of functioning are not described sufficiently enough to determine the scale of the problem or the role of an environmental factor.In these areas, it was also not possible to demonstrate any improvement.Clinicians will have to find appropriate outcome measures for assessing these categories.
Another advantage of the ICF lies in its easy and language-independent format that is especially important in the united Europe and the globalised world of today.Being neutral, ICF also underlines the strong sides of an individual that are important for rehabilitation and further functioning.However, little information was found in relation with the environmental factors.Therefore even in cases when conventional medical records have been already created ICF may help to structure the information about functioning in a clear, easy and holistic way.
The study revealed that some aspects of functioning are currently not sufficiently described in the medical records.In the future, ICF could help professionals to draw more attention to the important aspects of functioning and the environmental factors relevant for functioning.

ICF as a tool to organize clinical information and evaluate the outcome of rehabilitation
Another retrospective study conducted in Slovenia involved analysis of the medical records of 100 patients with brain injury admitted to the URI.Its goal was to explore to what extend the ICF can be a useful tool to organize existing clinical information and to retrospectively evaluate the effect of interventions in patients with BI (Ptyushkin et al. 2010).Overall (i.e., for all the patients included in the study, at admission and/or at discharge), 51 codes for body functions, 22 for body structures, 62 for activities and participation, and 35 relevant environmental factors were identified.They are presented in the Tables 6-9 below.As it can be seen from Table 6, three major groups of functional problems corresponding to the list of body functions were identified: related to mental functions (15 out of 51 codes or nearly 30%), related to sensory functions (12 out of 51 codes or nearly 24%), and related to mobility (8 out of 51 codes or nearly 16%).Functional problems were also frequently found for speech (b310, b320 and b330).Major improvements were found regarding orientation functions (b114), energy and drive functions (b130), memory functions (b144), mental functions of language (b167), vestibular functions (b235), sensation of pain (b280), voice and articulation functions (b310 and b320), ingestion functions (b510), defecation and urination functions (b525 and b620), mobility and muscle power functions (b710 and b730), and control of voluntary movement functions (b760).Little or no changes were observed for most of the mental functions.Worsening of a body function was detected in three patients -one in perceptual functions (b156), one in sensation of pain (b280), and one in control of voluntary movement functions (b760).Table 6.Body Functions (all values are no. of cases, which equal percentages since n=100).
Table 7 shows that the general profile of the patients regarding body structures corresponds to the diagnoses according to the ICD-10.Some of the structures are related to the TBI itself or concomitant injuries (structure of the brain and spinal cord, structure of head and neck region and extremities).Others (like structure of cardiovascular or respiratory system) reflect the comorbidities of the patient.
Restrictions in activities and participation (Table 8) were frequently found in acquiring skills (d155), reading and writing (d166 and d170), solving problems (d175) and undertaking a task (d210 and d220).Another group of common restrictions is related to communicationreceiving messages (d310 and d315), speaking (d330), writing messages (d345) and conversation (d350).Frequently there were also disturbed activities related to mobility (changing and maintaining a body position, transferring oneself, walking and moving around) and very Table 7. Body Structures (all values are no. of cases, which equal percentages since n=100).
frequently those related to self-care (d510-d570).Finally problems were found frequently in the areas of interpersonal relationships (d710 -d770), in acquiring, keeping and terminating a job (d845) and recreation and leisure (d920).Considerable improvements at the discharge were detected in the following areas: acquiring skills, solving problems and receiving spoken messages, mobility (d410-d460) and self-care (d510 -d560).Improvement was also found for general interpersonal interactions (d7).Worsening was frequently found for driving (d475).Worsening was also found once for complex interpersonal interactions (d720), formal relationships (d740) and acquiring, keeping and terminating of a job (d845).
Based on the medical records, 35 environmental factors were identified in the 100 studied individuals.Twenty of them, which are presented in Table 9, were present in the majority of patients.Some of those environmental factors may act both as facilitators and barriers in different patients.For example, the role of the immediate family (e310) may be either a strong facilitator of equally strong barrier for rehabilitation.After linking, it became clear that the three major groups of functional problems regarding body functions in patients after TBI are related to mental functions, sensory functions and mobility.Another important group is related to speech.The improvements found at the end of rehabilitation for mobility-related functions (b710-b770), and in some patients for speech functions, can be explained by the fact that the current rehabilitation program is mainly focused on these particular aspects of functioning.At the same time much less improvement was observed for mental functions with the exception of orientation, energy and drive functions and memory, although the patients were assessed and advised by a psychologist.This important difference in the evolution of mental and physical consequences is very common in patients after the TBI.It can be also related to the fact that the time of rehabilitation is usually too short to produce and detect substantial changes at the level of mental functions.The general profile of patients regarding body structures corresponded to the diagnoses according to the ICD-10.Some of the structures are related to the TBI itself or concomitant injuries (structure of the brain and spinal cord, structure of head and neck region and extremities).Others (like structure of cardiovascular or respiratory system) reflect the comorbidities of the patient.
Restrictions in activities and participation found in the study were frequently caused by or related to the disturbances in mental functions (like acquiring skills, reading and writing, solving problems and undertaking a task) and generally show little to moderate changes from the admission to the discharge.Another large group of restricted activities and participation which showed considerable improvement was related to mobility functions (11 out of 62 codes or nearly 18%).Notable improvements were also found in activities related to selfcare and this can be explained by the fact that the work of nurses and occupational therapists involved in the process of rehabilitation is mainly focused on these aspects of Table 9.The Environmental Factors found to be relevant for the majority of patients.

Environmental factors
functioning.More serious problems described for driving at the discharge were not because at the admission the driving abilities of the patients were necessarily better, but because during the rehabilitation they were found insufficient, often after being tested on the driving simulator and this was clearly stated at the time of the discharge.Some of the relevant environmental factors identified in the study may act both as facilitators and barriers in different patients.For example, the role of the immediate family (e310) may be either a strong facilitator of equally strong barrier for rehabilitation.The potential of the ICF to describe the impact of the environmental factors is an important strength of the classification and ICF-based tools.However, it should be mentioned that the study also revealed that insufficient attention is still drawn to the role of environmental factors for rehabilitation and after rehabilitation life of an individual.This can be due to the lack of suitable instruments for describing the environment.Gathering information about the environmental factors in a systematic and internationally standardized way can help take the influences of the environment more into consideration at all levels, and the ICF may be helpful in this respect.
The ICF also structures the large amount of information and provides a clear, easy and holistic view of all different aspects of functioning, reflected in different reports and documents.Another advantage of the ICF is in its easy and language-independent format that is especially important in a united Europe and globalized world of today.Being neutral, ICF can also underline the strong sides of an individual important for rehabilitation and further functioning.Frequent use of the qualifier "8" ("not specified") is mainly related to the fact that particular aspects of functioning are not described sufficiently enough to determine the scale of

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the problem or the role of an environmental factor.At the same time, the value of the qualifier "not specified" should not be underestimated as it draws attention to a particular aspect of functioning where based on the available information the level of the problem cannot be clearly defined.Activities and participation related with the daily life that are especially important for functioning after discharge (like Chapter 6, Domestic life, and Chapter 9, Community, social and civic life) were poorly described in the medical records.This indicates that still not enough attention is drawn to these aspects of human functioning during rehabilitation.We assume that in some cases it is very difficult if not impossible to assess these aspects of functioning during the hospitalization and it is only possible to predict that difficulties will be there when a person is back in his or her common environment.
A strength of the ICF is also in its capacity to describe the consequences of the comorbidities, i.e., conditions that are not related to the main condition (TBI).
In general it can be said that substantial improvement was found for those functions, activities and participation, the current rehabilitation program is focused on.Therefore the ICF may help in modifying the existing programs or adapting them to the individual cases.

Conclusions
Use of the ICF in brain injury rehabilitation interactively models functioning and disability associated with this health condition.The appropriate tools for daily practice such as ICF Core Sets for Traumatic Brain Injury allow to apply this interactive holistic approach into practice.ICF-based rehabilitation of the persons after brain injury facilitates truly interdisciplinary work by providing a common framework for all professionals involved in rehabilitation of such a patient.Practical ICF tools can allow specialists to speak the common professional language and extend the boundaries of rehabilitation making the whole process highly individualized on solving problems of a concrete patient thou rigorously standard.

Table 1 .
Overview of qualifiers for different components of the ICF

Table 3 .
Identification of a meaning unit and linking it to the ICF code and qualifier.

Table 4 .
Correspondence of FIM scores to the ICF qualifiers.

e120 Products and technology for personal indoor and outdoor mobility and transportation
Moving the whole body from place to place, on any surface or space, by using specific devices designed to facilitate moving or create other ways of moving around, such as with skates, skis, or scuba equipment, or moving down the street in a wheelchair or a walker.
d520Caring for body parts Looking afer those parts of the body, such as skin, face, teeth, scalp, nails and genitals, that require more than washing and drying.

Table 5 .
ICF-based functional profile of the patient (Cap=capacity, Per=performance).

Table 8 .
Activities and Participation -Performance (all values are no. of cases, which equal percentages since n=100).
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