(Return to the ICF for School-based Practice Webinar)
1. Introducing the ICF in school-based practice with adaptive equipment
Welcome. This is Lori Potts, physical therapist with Rifton Equipment, and this webinar is introducing the ICF for school-based practice, looking at adaptive equipment.
Be familiarized with the International Classification of Functioning, Disability, and Health (ICF)
Recognize the relevance of the ICF for the school-based practice environment
Recognize the use of adaptive equipment as an environmental intervention
By the conclusion of this webinar, you will have learned the basics about the ICF framework, and how it applies to school-based physical and occupational therapy. You will also understand the role of adaptive equipment as an environmental factor.
3. What is the ICF?
The International Classification of Functioning, Disability & Health
- Introduced by the WHO in 2001
- Endorsed by the APTA in 2008
The ICF is the World Health Organization’s most recent framework for health & disability. It was launched in 2001. In 2008, the APTA House of Delegates voted unanimously to endorse the ICF, so it is fully accepted by the PT profession. The ICF is now being incorporated into the current revisions of the Guide to Physical Therapist Practice. The ICF framework and approach to disability is very much in line with occupational therapy as well, and there are ICF resources available for purchase from AOTA’s online store. Our webinar will not go in depth into the actual use of the tool of the ICF – this is just a basic overview to understand the relevance of the ICF to school-based practice.
4. “Professionals can improve their interactions with people who have disabilities by viewing disability as a form of human diversity rather than a deficiency that needs to be changed…”
Michael Giangreco, PhD. ASHA 2000
Here is a quote that captures some of the significance of the ICF and how it changes our perspective: “Professionals can improve their interactions with people who have disabilities by viewing disability as a form of human diversity rather than a deficiency that needs to be changed…” Michael Giangreco is a Professor at The University of Vermont. He has done extensive work on inclusion services for students with disabilities.
5. So…what’s the ICF?
- Collection of data about the functioning in daily life of a person with a health condition
- It’s a way to re-frame your decision-making…
The ICF collects data to describe a person’s health and function in the presence of a disability. It differs from previous medical models, because the ICF places the emphasis on health and functioning, rather than on disability. The ICF measures a person’s function in society, no matter what the reason for impairment, and provides information for decision-making and intervention.
6. Nagi Model
Pathology >Impairment >Functional Limitation >Disability
Before we talk about the ICF, let’s look at the traditional medical model. Traditionally, the model that has been widely used in physical and occupational therapy practice has been the Nagi Model . The Nagi Model was developed in the US in the early 1960s. When the Guide to Physical Therapist Practice was first developed, it was based conceptually on this Nagi disablement model. You see here the four levels that the Nagi Model describes. Pathology is the underlying disease, disorder, or condition, such as cerebral palsy. Impairment is the abnormalities that result, that is, the anatomical, physiological or mental/emotional limitations or losses. For our student with cerebral palsy, this may be abnormal muscle tone. Functional Limitation describes problems with actions, tasks or activities, viewed as a consequence of impairment, such as the inability to transfer independently from one surface to another. Finally, Disability identifies the impact on the person’s behavior in life and society. For a student, an example might be the inability to participate in a school play with non-disabled peers. What you notice about the Nagi model is that it is linear in nature: Functional Limitations are viewed as a result of the Impairment due to the Pathology, and as a cause of Disability. This view bases our way of thinking on disablement. In other words, with the Nagi model, disability began where health ended – and once you were disabled you were in a separate category. With the ICF, we want to get away from this kind of thinking.
7. (Diagram of ICF Framework)
The ICF is an entirely different framework and view, as you can see here. With the ICF, Health is conceptualized as the intersection of body functions & structure, activities, and participation, with environmental and personal factors having an impact as well. You can see the bi-directionality of the arrows in between, showing the dynamic interaction between these components. In the ICF, the new terms “Body Function and Structure” and “Impairment” replace the Nagi term for “Impairment”. The new terms “Activities” and “Activity Limitation” replace the Nagi term for functional limitation. And the new terms “Participation” and “Participation Restriction” replace the Nagi term for “Disability.” With the ICF the words “Functioning” and “Disability” become umbrella terms, as we’ll discuss further. Part 2 of the ICF looks at Contextual Factors – the environmental and personal factors. The environmental factors are outside the person, while the personal factors are those characteristics specific to the person that are not part of their health condition. One of the key points here is that as school therapists we are in a unique position to be able to change the environment (through the use of assistive devices, for example) to such a degree that we can impact the child’s participation. This is huge – for most of our students, we may only have minimal impact on body structure and function (as with the traditional approach), but a huge impact is possible through altering the environment factors. As school based therapists, we have the opportunity to make a significant impact on the environment – perhaps more than any other area of practice. In fact, environmental intervention can become a primary focus – and very often, this is the only way to improve participation.
8. Overview of the ICF 2 parts:
Part 1 Functioning and Disability
includes Body Function and Structures, Activities and Participation
Part 2 Contextual Factors
includes environmental factors and personal factors
Here is Part 1 and Part 2 of the ICF. Part I, Functioning and Disability, is the description of the person’s overall health. “Functioning” is now a term for the broader concept of the student’s ability to function at all levels: body functions and structure, activity, and participation. Functioning describes the positive. “Disability” is now an overall term for the inability to function, and is used to indicate the problems in body function and structures or impairments, as well as any activity limitations, and participation restrictions. Part 2 is the Contextual Factors – the personal factors within the person as well as the environmental factors around the person. These have a very big impact, and the ICF recognizes this impact.
9. Part 1: We can describe the positive!
- Body structure & function
- Activity Limitations
- Participation Restrictions
With the ICF, we can describe the positive! We are looking at function at three levels: at the level of the body, at the level of activity (or ability for a task), and at the level of participation in life and society. Remember: Functioning and Disability are terms to describe the broad concepts of an individual’s function or inability to function. With the ICF, we’re no longer looking at the donut hole: we’re looking at the donut! We want to focus on what a student CAN do, despite any impairment. We take into consideration what the student can or can’t do (the activity) and how they participate (both the positives and negatives) and we can see how all aspects of health come together. With the ICF in school-based practice, the impairments, limitations and restrictions can be positively and significantly affected by the environmental factors and personal factors. For this student, it was personally important to him to wash his hands at the sink as did his peers. Due to deficits in leg strength and postural balance and control, and due to the size of his wheelchair, he was unable to access the sink. However, use of an adaptive chair is an intervention that alters the environment, enabling the activity. Even though the intervention did not directly alter his body structure and function, it has promoted his participation with peers. The ICF is very different from the traditional medical view that tries to improve function by addressing the impairment. Instead, the ICF considers the impact of the environment. Is the environment a barrier or does it facilitate function? Let’s take a closer look at the ICF definitions.
10. Definitions – Functioning
Body functions – physiologic
Body structures – anatomic
Activities – task or action
Participation – involvement in life
Here are the ICF definitions for functioning. Body functions are physiological functions of body systems (including psychological functions). Body structures are anatomical parts of the body such as organs, limbs, and their components. Activity is the execution of a task or action by an individual. Participation is involvement in a life situation.
11. Definitions – Disability
Impairment – loss or deviation of body part or structure
Activity limitation – difficulty with an activity
Participation restriction – problem with involvement in life
Here are the ICF definitions for disability: Impairments are problems in body function or structure such as a significant deviation or loss. Activity Limitations are difficulties an individual may have in executing activities. Participation Restrictions are problems an individual may experience in involvement in life situations.
12. The ICF describes changes…
The ICF describes changes
Body function/structure - within the person
Activity – the whole person and the task
Participation – the person’s role and involvement in life
- And the ICF includes contextual factors…
Environmental / Personal
So, the ICF is documenting the person’s status at three levels: the person, the activity, and his or her ability to participate. It can of course be somewhat challenging to differentiate between Activity and Participation. We can think of Activity, and Activity limitation, which is a problem with the execution of a task or action, as being at the level of the individual: what the person is able to do. We can think of Participation and Participation restriction, which is a problem with involvement in a life situation, as being at the level of the person’s role in life, in the person’s everyday surroundings in society. The ICF has intentionally decided to place the activity and participation descriptions into one list. This allows the differentiation between Activity and Participation to be made as appropriate in each case. So the ICF has created one list for body functions and body structures, and another list for activity and participation. Although we will not explain this in full detail, it is important to recognize the thorough and detailed information available. Codes are used to classify and describe the person’s health and the use of qualifiers rates the presence of a problem and how severe it is. We can see whether the environment is a barrier to function or helps to facilitate function. In this way, overall improvement can be documented and measured. Because the ICF emphasizes the impact of the environment, the contextual factors are an important component. We’ll look at that next.
13. Part 2: Contextual Factors
physical, social, attitudinal
examples: gender, age, social background, past and current experience, coping style, behavior pattern, character
Part 2 of the ICF looks closely at the environmental factors. These are external or outside of the person. They make up the physical, social, and attitudinal environment in which people live and conduct their lives. These factors include products and technology, environmental conditions such as architectural modifications, climate, terrain, and the social attitudes that surround the person. The legal and social structures of society are considered environmental factors as well. Personal Factors are internal to the person and have an impact on their character and overall behavioral pattern, as you can see with his list of examples. These factors influence how disability is experienced by the individual. The contextual factors really can have a significant impact, which is why the ICF includes them.
14. Environmental Factors
- Products and technology
- Natural environment and human made changes to the environment
- Support and relationships
- Services, systems, and policies
Here is a closer look at the listing of environmental factors from the ICF. I won’t read the list but you can see there are a wide range of environmental factors, all of which can have a profound influence on a person’s disability and functioning. Products and technology are on the top of the list.
15. Dimensions of the ICF
- Health conditions
- What is the child’s health status?
- How does child’s body/mind function?
- How does the child perform daily life activities?
- How is the child involved in roles/situations?
- What are the things, conditions, and circumstances surrounding the child?
So the ICF broadens our assessment and intervention beyond just the medical status to the whole daily living experience. Again, I won’t read this list, but as we look at the dimensions of the ICF, we can see how the ICF moves away from the negative connotations of the Nagi Model. With the ICF, emphasis is on positive outcomes to be sought rather than the negative consequences of the pathology. The exciting thing about the ICF is that it turns our attention to the function of the student or person as a whole in the context of their environment. What does the student want to do in personally important contexts?
a. Goal = typically an activity
b. Intervention = directed at impairment
c. Participation first
d. Intervention = beyond impairments
This new perspective changes our intervention as well as our assessment. Historically, with the Nagi model, our therapy goals have been about doing an activity – and our interventions have focused on correcting or alleviating impairment. But this approach had its drawbacks. If we’re honest, we’ve found that impacting impairment does not necessarily change the level of function. As an example – Does doing quad strengthening exercise necessarily improve walking ability from the bus to the classroom? We cannot necessarily assume that attempting to alleviate an impairment, such as weakness of the quads, is the best or the only means for achieving a functional activity such as walking in the school hallway. With the ICF, the focus is now on Participation. The child and family determine what they want the child to be able to do in socially important contexts. The ICF acknowledges that a change to the environmental factors can make the difference. For example, by providing a supportive walking device, and training school personnel in its use, you will both enable walking in the school hallway, and in the process, to some extent alleviate the impairment, as a byproduct of the intervention, and increase the child’s independence in gait. Intervention with the ICF goes beyond mitigating impairments. With the ICF, we consider: can we alter the environment, can we alter the task or activity, can personal factors be influenced? – all this can enable participation.
17. Utilizing the ICF
An automatic association between severity of impairment and level of function cannot be made
In other words, an automatic association between the severity of impairment and the level of function cannot be made. What exactly does this mean? We can no longer assume a direct relationship between the severity of impairment and the child’s functional independence. With the ICF, contextual factors interact with the person with a health condition and determine the level and extent of the person’s functioning. For example, environmental factors would include an assistive device, and the personal factors includes the child’s own motivation: these factors can significantly overcome activity limitation and participation restriction. With the ICF, we no longer just assume a child is unable to do something due to impairments – often he or she can, when provided with the right supports.
18. ICF and school-based practice
Consider all ICF components for both assessment and intervention
- Components of Health: Body (individual), Activity (person/task), Participation (real-life)
- Contextual Factors: Environment, Personal
Capacity vs. performance
- Identify/reduce the barriers and enhance the supports
Now we’ve become familiarized with the ICF and can recognize the relevance of the ICF for the school-based practice environment. Children who are unable to participate fully are considered to be disabled. As school-based therapists, we identify the factors related to the student’s ability to access and participate in school. With the ICF, this includes looking not only at body function and structure impairments, but also looking at any difficulties in doing a task (activity limitations) and problems with participation (participation restrictions). Our therapy intervention targets these levels as well. With the ICF, the school therapists’ role is to identify and mitigate any barriers that exist, and to increase the student’s ability to participate. Our role is not solely to alleviate impairments, but goes beyond this to assure access to the school environment.
19. ICF – Capacity vs Performance
The ICF also records information on capacity and on performance. In this way, the ICF helps to bring the focus to the environmental factors and specifically the environmental supports.
20. ICF – Capacity vs Performance
- Capacity: in a standardized environment
—Capacity can indicate the level of functioning without supports
—(may not be very useful for knowledge about performance)
- Performance: in their usual environment
—Is what a child does do in everyday settings, given the environment supports
Capacity relates to Activity – and the ability of the person to perform a task or activity – that is, the person’s level of functioning without supports. Information about capacity may not necessarily be useful in determining what a child does in the home, school, and community. It is Performance that is the reflection of what a child does in everyday settings. Performance describes what a person actually does in the current environment, and so it relates to Participation. And what makes the difference between Capacity and Performance? The environment. With capacity, we’re looking at just what the individual can do in and of themselves. With performance, we’re looking at the real life situation with environmental supports. The gap between capacity and performance is due to the difference between a uniform, standard environment as compared to the actual daily living environmental circumstances.
21. Environment: make or break
Capacity vs Performance
- Capacity is greater than Performance
—Environment is a barrier
- Performance is greater than Capacity
—Environment has facilitated!
Because the ICF gives us data about capacity and performance, this means the ICF enables us to determine the ‘gap’ between capacity and performance. If capacity is greater than performance, then some aspect of the real life environment is a barrier to performance. The student did better in the standardized setting. If capacity is less than performance, and performance is greater than capacity, then the person’s current environment has enabled him or her to perform better: so the environment has facilitated performance. For school-based practice: We want to close the gap – to eliminate the barriers – and facilitate performance!
- By increasing activity and participation, the body impairments may be alleviated as a by-product of the intervention
- Constraints in body function and structure, not amenable to change, can be overcome with environmental supports
Here’s an example. This student is completely focused on class participation, but she is building head and trunk control in the process. We don’t know if she will ever be able to stand independently, but the equipment enables her to be in a standing position alongside her peers. You can see that by stabilizing the one arm, this student has better use of the arm that is free. And being upright gives her the opportunity for weight-bearing as well as facilitating alertness and engagement. But the primary focus of the intervention is participation and access to the school environment. By increasing activity and participation, the body impairments may be alleviated as a byproduct of the intervention. Those impairments not amenable to change can be overcome with environmental supports.
23. Outcome — as defined by the ICF
A quality of life change that enables engagement in everyday settings
The ICF defines outcome as a quality of life change that enables engagement in everyday settings. The outcome does not necessarily correlate with changes to body function and structure. So we can recognize the use of adaptive equipment as an environmental intervention that will promote functional outcomes. As an example: a student in a wheelchair may have extreme spastic extensor tone that forces him into full extension and into a sacral sitting position. But with an adaptive seating device, the student can have the opportunity to perform an activity and participate. Here you see the Activity Chair seat angled forward, the backrest also positioned forward for a slightly acute angle at the hips, and the foot rest tucked back for some knee flexion. In this way, the extensor tone can be dramatically reduced. Then, with the student’s left arm secured in the forearm prompt, he can better hold his head and use his right arm with the communication device. Even though he may not be able to do it for very long because of underlying trunk weakness, repeated opportunities can help to improve his stamina over time.
- The person is not defined by their deficits but rather by their engagement in daily activities despite limitations
- It’s about participation; it’s not impairment driven
- It’s about what the person wants and can do versus deficit–focused
So this is what’s great about the ICF. The person is not defined by their deficits but rather by their engagement in daily activities despite limitations. It’s about participation; it’s not impairment driven. It’s about what the person wants to do and can do versus being deficit–focused. As school-based therapists, our focus is on the student’s ability to access and participate in school. Our role is not solely to alleviate impairments. As we address participation in school activities and routines, some impairments may be alleviated, but the focus is on Activities and Participation.
In this cartoon Dr. Michael Giangreco captures the change in thinking that the ICF requires.
Take Home Points about the ICF
- “Mainstreams” the experience of disability
- Focuses on health in the presence of disability
- Changes emphasis from deficit to enablement
- Optimizes function in the context of the environment
•So the ICF “Mainstreams” the experience of disability – it applies to all people across the health spectrum, and no longer categorizes persons with disabilities as a separate group.
•The ICF stresses health in the presence of disability, and moves away from the idea of an individual being handicapped by his/her diagnosis. The ICF describes function or inability to function and emphasizes the health status rather than medical deficits.
•The ICF places the focus on enablement and function, and changes the emphasis from focusing on the impairments to looking at activity and participation. So the focus shifts from the cause to the impact.
•This includes the impact of the environment. Interaction with the environment is a key dimension of the ICF – and whether the environmental factors are a barrier or whether they facilitate participation, to increase function and thus lessen the disability.
27. Diagram of Framework
So as we wrap up this webinar, remember the ICF framework! Traditionally, the medical model has focused on the areas shown here in white: the body functions and structures, along with consideration of the personal factors – all of which are internal to the person. The red color emphasizes the areas that are external to the student’s intrinsic factors, and that also significantly impact overall health. With the ICF, we now broaden our focus to these other dimensions: the ability to execute tasks and activities, and how these may be modified to improve function, and involvement in life situations, and how barriers can be reduced or eliminated to increase participation. The environmental factors now have an instrumental role in intervention. This slide concludes this webinar. There are a few more slides to follow, with web links to explore further ICF resources available on the World Health Organization website. Thank you for your attention!
28. www.who.int for the ICF checklist
Access the ICF checklist online
29. www.who.int for the ICF-CY ONLINE
Children and Youth version
Locate the ICF Children and Youth version online
30. World Health Organization. (2002)
ICF Application and Training Tools. ICF Training Beginner’s Guide: Towards a Common Language for Functioning, Disability and Health. ICF. Geneva 1-22.
Download the ICF Beginner’s Guide (pdf) (This Guide was a primary resource for this webinar.)
31. Thank you for your time and attention.
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