International Classification of Functioning, Disability and Health (ICF)

Original Editors - Laura Ritchie

Top Contributors - Laura Ritchie, Naomi O'Reilly, Kim Jackson, Admin, Shaimaa Eldib, Lucinda hampton, Merinda Rodseth, Oyemi Sillo, WikiSysop, Nicole Hills, Ewa Jaraczewska, Rachael Lowe, Tarina van der Stockt, Simisola Ajeyalemi and Lauren Kwant      

Introduction

The International Classification of Functioning, Disability and Health (ICF) is a framework for describing functioning and disability in relation to a health condition. It provides a common language and framework for describing the level of function of a person within their unique environment or in other words, what a person with a specific health condition can do in a standard environment (their level of capacity), and also what they actually do in their usual environment (their level of performance). as opposed to classifying the person by their having a specific condition or as a 'Yes/No' answer regarding disability. World Physiotherapy adopted a motion supporting the implementation of the ICF in physiotherapy in 2003.

The ICF is a framework to approach patient care that shifts the conceptual emphasis away from negative connotations such as disability and places focus on function and the positive abilities of the individual at the patient level rather than the systems level. The below video (3.47 minutes) gives a good introduction to the ICF.

Components of the ICF

The ICF focuses on three components, which underscores the importance of the interplay and influence of both internal and external factors to each individual’s health status.:

• Body Functions and Structures
• Activities and Participation (at individual and societal levels)
• Personal and Environmental Factors (at a contextual level).

The ICF Model

Body Functions and Structures

Definitions:

• Body Functions: The physiological functions of body systems (including psychological functions)
• Body Structures: Anatomical parts of the body such as organs, limbs and their components
• Impairments: Problems in body function and structure such as significant deviation or loss

Examples:

• b28010 Pain in head and neck
• s720 Structure of shoulder region
• s810 Structures of areas of skin

Note that codes relating to body functions start with 'b' while codes relating to body structures start with 's.'

Activities and Participation

Definitions:

• Activity: The execution of a task or action by an individual
• Activity Limitations: Difficulties an individual may have in executing activities
• Participation: Involvement in a life situation
• Participation Restrictions: Problems an individual may experience in involvement in life situations

Examples:

• d230 Carrying out daily routine
• d420 Transferring oneself
• d475 Driving
• d530 Toileting
• d910 Community life
• d920 Recreation and leisure

Note that codes relating to both activities and participation start with the letter d.

Environmental Factors

Definition:

The physical, social and attitudinal environment in which people live and conduct their lives. These are either barriers to or facilitators of the person's functioning.

Examples:

• e115 Products and technology for personal use in daily living
• e155 Design, construction and building products and technology of buildings for private use
• e210 Physical geography
• e355 Health professionals

Note that codes relating to environmental factors start with the letter e.

Personal Factors

Personal Factors should also be considered in this model but are not classified within the actual ICF framework.

Contents of ICF Components

Each component is divided into a hierarchy with an additional digit added to the classification code for each subsequent layer in the hierarchy. The hierarchy is as follows;

• Component e.g. Activities and participation
• Chapter e.g. Mobility (Chapter 4)
• Block e.g. Walking and Moving (d450-d469)
• Two-level Category e.g. Moving around in different locations (d460)
• Three-level Category e.g. Moving around within the home (d4600)

Measurement

A generic qualifier scale can be used to record the extent of the problem for each identified impairment, activity limitation and participation restriction. Environmental factors can also be qualified as either barriers or facilitators.

	Qualifier for Impairments of Body Functions & Structures	Qualifier for Impairments of Activities & Participation
0	No impairment	No difficulty
1	Mild impairment: Present <25% of time, with tolerable intensity, occurring rarely over last 30 days	Mild difficulty Present <25% of time, with tolerable intensity, occurring rarely over last 30 days
2	Moderate Impairment Present <50% of time, with intensity that interferes with day to day lift, occurring occasionally over last 30 days	Moderate Difficulty Present <50% of time, with intensity that interferes with day to day lift, occurring occasionally over last 30 days
3	Severe Impairment Present >50% of time, with intensity that's partially disrupting day to day lift, occurring frequently over last 30 days	Severe Difficulty Present >50% of time, with intensity that's partially disrupting day to day lift, occurring frequently over last 30 days)
4	Complete Impairment Present >95% of time, with intensity that's totally disrupting day to day life, occurring daily over last 30 days	Complete Difficulty Present >95% of time, with intensity that's totally disrupting day to day life, occurring daily over last 30 days
8	Not Specified Insufficient information	Not Specified
9	Not Applicable	Not Applicable

	Qualifier for Environmental Barriers		Qualifier for Environmental Facilitators
(.0)	No barrier	(+0)	No facilitator
(.1)	Mild barrier	(+1)	Mild facilitator
(.2)	Moderate barrier	(+2)	Moderate facilitator
(.3)	Severe barrier	(+3)	Substantial facilitator
(.4)	Complete barrier	(+4)	Complete facilitator
(.8)	Barrier, not specified	(+8)	Facilitator, not specified
(.9)	Not applicable	(+9)	Not applicable

Explaining Walking Activity by using ICF model

Performance versus Capacity

Definitions;

• Capacity: what a person can do in a standardised environment e.g. during clinical assessment. It indicates the extent of activity limitation as a direct manifestation of a person's health status, without any assistance (assistance of another person, equipment or environmental modification).
• Performance: what a person actually does in his/her usual environment e.g. at home. It indicates the extent of participation restriction or the "lived experience" by describing all physical, social and attitudinal environmental factors. It measures the difficulty a person experiences in doing things, assuming that they want to do them.

The gap between these two constructs reflects the impact that different environments can have on activities and participation. This gap can then guide intervention (e.g. on environmental factors) to help improve a patient's performance.

ICF Core Sets

The ICF Core Sets were developed as a practical tool to facilitate the systematic and comprehensive description of functioning in clinical practice. They are compiled in order to provide health care professionals with a better understanding of the needs of their patient populations. Core sets for twelve chronic diseases were initially developed because of their prevalence and the significant impact on function they can cause. These twelve diseases are;

Chronic Diseases	Additional Core Sets Specific Conditions	Additional Core Sets Specific Settings
Breast Cancer Chronic Ischaemic Heart Disease Chronic Obstructive Pulmonary Diseases Chronic Widespread Pain Depression Diabetes Mellitus Low Back Pain Obesity Osteoarthritis Osteoporosis Rheumatoid Arthritis Stroke	Amputation Ankylosing Spondylitis (Axial Spondyloarthritis) Attention Deficit Hyperactivity Disorder (ADHD) Autism Spectrum Disorder Bipolar Disorder Cerebral Palsy Hand Conditions Head and Neck Cancer Hearing Loss Inflammatory Bowel Disease Multiple Sclerosis Schizophrenia Sleep Spinal Cord Injury Traumatic Brain Injury Vertigo	Neurological conditions in acute and post-acute care Acute and post-acute care Geriatric patients in post-acute care Rehabilitation Vocational Rehabilitation

Additional Core Sets have subsequently been developed for various other conditions and populations including;

• Amputation
• Ankylosing Spondylitis (Axial Spondyloarthritis)
• Attention Deficit Hyperactivity Disorder (ADHD)
• Autism Spectrum Disorder
• Bipolar Disorder
• Cerebral Palsy
• Neurological conditions in acute and post-acute care
• Acute and post-acute care
• Geriatric patients in post-acute care
• Hand Conditions
• Head and Neck Cancer
• Hearing Loss
• Inflammatory Bowel Disease
• Multiple Sclerosis
• Rehabilitation
• Schizophrenia
• Sleep
• Spinal Cord Injury
• Traumatic Brain Injury
• Vertigo
• Vocational Rehabilitation

All available core sets can be viewed here.

Families and the ICF

ICF in Relation to Wheelchair Users

Please see this page for information on use of the ICF in relation to users of wheelchairs.

Resources

WHO Resources

1. Towards a Common Language for Functioning, Disability and Health: A guide for beginners
2. A Practical Manual for using the International Classification of Functioning, Disability and Health
3. ICF e-Learning Tool
   • The introductory module of the ICF e-Learning Tool is online and is available in several languages. The introductory module is ideal for anyone interested in learning about the ICF.
4. ICF Browser 
   • Using this online browser you can see the structure of the classification, look up the codes and definitions, create your own shortlists of ICF codes and view the classification in more than one language.
5. ICF Core Sets
   • Access to all current ICF Core Sets
6. ICF Checklist 
   • The user–friendly display of the most relevant ICF categories for clinical purposes. The checklist allows the user to identify and qualify the individuals functioning profile in a simple and time-efficient manner.
7. ICF Case Studies
   • To illustrate the use of the International Classification of Functioning, Disability and Health (ICF) in rehabilitation practice, Swiss Paraplegic Research initiated the project "Case studies" in 2007. Using ICF tools within the framework of the "Rehab-Cycle", it follows the rehabilitation journey of a number of individuals with a spinal cord injury.

Videos

References