Disablement Models, ICF Framework, and Clinical Decision Making

CHAPTER 1


Disablement Models, ICF Framework, and Clinical Decision Making



LEARNING OBJECTIVES


After reading this chapter and completing the exercises, the reader will be able to:


1. Define a functional outcome and discuss its importance in physical therapy documentation.


2. Identify and describe three historical models of disablement.


3. Define the components of the International Classification of Functioning, Disability, and Health (ICF) model.


4. Classify clinical observations and measurements according to the ICF.


This book outlines a method for physical therapy documentation and clinical decision making based on the general principle that documentation should focus on functional outcomes. An outcome is a result or consequence of physical therapy intervention. A functional outcome is one in which the treatment effect is the individual’s ability to accomplish a goal that is meaningful for that individual. Functional outcomes should be the focus of physical therapy documentation:



Traditional physical therapy documentation formats do not easily adapt to a functional outcomes focus. Therefore several authors have attempted to present documentation formats that are generally referred to as functional outcomes reports (FOR) (Stamer, 1995; Stewart, 1993). The FOR format presented in this book is based in part on ideas derived from these published documentation formats and the authors’ own clinical and teaching experience.


This book has two main purposes: (1) to provide a framework for clinical decision making that is based on a functional outcomes approach and (2) to provide guided practice in writing functional outcomes documentation.


Clearly there is no single correct way to write physical therapy documentation. Documentation must be adapted to the context in which it is written. The purpose of this book is therefore not to present a rigid format for writing documentation. Instead, the book offers a set of guidelines for writing documentation in a functional outcomes format. This set of guidelines is flexible and should be adaptable to many different practice settings.


The framework for documentation presented herein is based on the now widely accepted International Classification of Functioning, Disability and Health (ICF) model of how pathologic conditions lead to disability. Until 2008, the American Physical Therapy Association (APTA) endorsed the Nagi framework as a guiding disablement framework (Nagi, 1965, 1991). In fact, the Nagi model is an integral part of the current version of the Guide to Physical Therapist Practice (the Guide) and the first edition of this textbook. In July 2008, the APTA joined the World Health Organization (WHO), the World Confederation for Physical Therapy, the American Therapeutic Recreation Association, and other international organizations in endorsing the ICF model. Accordingly, we have adapted the documentation format in this textbook to the ICF model.


To the extent possible, we have incorporated the Guide into our documentation framework. The main purpose of the Guide is to “help physical therapists analyze their patient/client management and describe the scope of their practice” (APTA, 2001, p. 12). Importantly, the Guide has helped to establish a common set of definitions and physical therapy terminology. This book attempts to use that terminology in addition to an overall conceptual framework that is consistent with that of the Guide.


In this chapter, we discuss the history of disablement models and development of the ICF model. We also consider how this model can be used to understand the role of physical therapists (PTs) in the diagnostic process and planning appropriate interventions. Finally, the importance of the ICF framework to documentation is discussed. The exercises at the end of the chapter provide practice in classifying conditions according to the Nagi model.



Historical Perspective of Disablement Models


The use of disablement models as an organizing framework for physical therapy was one of the key conceptual developments of the 1990s (Jette, 1994). Various models of disablement have been developed and explored, including the original WHO model (1980), the Nagi model (1965), and the National Center for Medical Rehabilitation Research (NCMRR) model (National Advisory Board on Medical Rehabilitation Research, 1991). These models are illustrated in Figure 1-1. Despite differences in terminology, each model provides a framework for analyzing the various effects of acute and chronic conditions on the functioning of specific body systems, basic human performance, and people’s functioning in necessary, expected, and personally desired roles in society (Jette, 1994).


image
FIGURE 1-1 Different models of the disablement process.

The differences among the various disablement models represent more than simple differences in terminology; important theoretical differences also exist (which are beyond the scope of this book). Nevertheless, these differences are small compared with the overwhelming similarity of the models. All the models are based on the assumption that the process of disablement can be analyzed at multiple levels. In the 1990s the Nagi model gained considerable acceptance in North America, whereas the WHO model has been used more widely in Europe, Australia, and Asia.


Disablement describes the consequences of disease in terms of its effects on body functions, the ability of the individual to perform meaningful tasks, and the ability to fulfill one’s roles in life. The arrows in Figure 1-1 imply a causal chain leading from active pathology to disability using the Nagi model as an example. Indeed, the causal links between elements in the models are useful; they help to conceptualize the relationships between findings at different levels. Nevertheless, the arrows often were interpreted as indicating a temporal series of events, which many health professionals found problematic. Furthermore, it was believed that these models did not capture the complexity of the relationships between different levels that were often multidirectional.



INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH


In 2001 the WHO revised its disablement model to address the criticisms of current models. The ICF seeks to use the positive terms activity and participation to redefine what Nagi refers to as functional limitation and disability. Thus although the general structure is similar to the original WHO model and the Nagi model, the focus of this new model is on the “positive” (“ability”) aspects of disablement.


In this new model, the process of disablement is a combination of (1) losses or abnormalities of body function and structure, (2) limitations of activities, and (3) restrictions in participation (Figure 1-2). Of note, the terms activity and participation focus on a person’s abilities versus inabilities or disabilities. As shown in Figure 1-2, the ICF model relinquishes the notion of simple, unidirectional causal links between levels. The individual’s pathologic state (health condition) becomes a broader category that influences all other levels. Furthermore, contextual factors—both extrinsic (environmental) and intrinsic (personal)—are specifically identified as affecting the relationship between body structures and functions and activities, and participation. Personal factors can consist of such things as family support, whereas extrinsic factors might include environmental barriers. These important additions highlight the multiple factors that can be related to any one person’s “disability.”


image
FIGURE 1-2 The ICF model of disablement.

The ICF is endorsed by the WHO as the international standard used to measure health and disability (resolution WHA 54.21). In addition to the overall model presented in Figure 1-2, the ICF provides definitions (Box 1-1) and detailed descriptions of what each “level” encompasses (Figure 1-3). Figure 1-3 provides sample descriptions from the ICF framework that could be used for a patient who has had a stroke and has gait impairments, mobility limitations, and faces environmental barriers in the workplace. Within each of the ICF domains there is a hierarchy of description (Chapter, second, third, and fourth levels as needed). This ultimately leads to a code that can be used to refer to a specific domain. These definitions and codes provide common terminology that can be used by all health professionals, whether describing individual patient characteristics (as in Figure 1-3) or conducting large-scale population-based research.



BOX 1-1   Definitions of the Components of ICF



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Jun 22, 2016 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Disablement Models, ICF Framework, and Clinical Decision Making

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