Clinical Reasoning for Therapy -

ICF Framework

Dr. Kavitha Raja PT, PhD

 Clinical reasoning for therapy

 Hypothesis generation – diagnosis

 Deficit identification
 Selection of outcome measure
 Management strategies
 Changes in management options
 Follow up plan
 Educational strategies
 Inter-disciplinary documentation
 Whole person approach rather than diagnosis
 All of our targets may be influenced by various factors and not just the
diagnosis

 Hence the ICF framework works well

Deformity, ADL Participation

Societal Barriers Employment

 ICF

 Endorsed in May 2001

 From “function to context”

 Changes in body function and structure

 What a person can do in a standard environment (level of capacity)
 What a person can do in their usual environment (level of performance)
 Performance is not expected to reach capacity levels (important while setting
goals)
 Outcome measures for therapy
 An outcome measure is the result of a test that is used to objectively
determine the baseline function of a patient at the beginning of treatment

 The instrument should also be convenient to apply for the therapist and
comfortable for the patient
 Outcomes and ICF

 The domains of ICF describe the three parts of therapy typically documented:

 The therapy goal based on the hypothesis and outcomes chosen

 The intervention strategy or strategies used to accomplish the goal

 The expected outcome of the intervention (+ CF)

Darrah, 2008
 Outcomes and ICF
Therapist’s goal Intervention Expected outcome

ICF domain Ability to straighten Specific resisted Increased quadriceps

knee against gravity exercises strength

ICF component of body function

 Outcomes and ICF
Therapist’s goal Intervention Expected outcome
Strengthen a child’s Specific resisted Improvement in
ICF domain quadriceps muscle exercises functional stair
with a qualifier climbing
(MMT of 4+)

ICF component Body function Activity

 Outcomes and ICF
 By identifying the components represented, we can be more aware of the
assumptions we are making and realize the need to systematically evaluate the
relationship of these assumptions

 Improvement in muscle strength leads

to improvement in stair climbing – is
there a possibility for muscle strength
to improve? Should we consider a
compensatory strategy?
 Outcomes and ICF
 By identifying the components represented, we can be more aware of the
assumptions we are making and realize the need to systematically evaluate the
relationship of these assumptions

 Clinical evaluation of the interactive

relationship across the components of
the ICF – is there a direct and simple
relationship or are there complexities
associated with CF?
 Relationship between the focus of their interventions
and their expected outcomes
Expected relationship between ICF components
Intervention at component of body function and
structure to achieve improvement at component of
body function and structure
Intervention at component of body function and
structure to achieve improvement at component of
activity
Intervention at component of activity to achieve
improvement at component of body function and
structure
Intervention at component of participation to achieve
improvement at component of participation
Clinical examples
Passive stretching to increase joint range
of motion. Tone reduction to improve
grasp
Passive stretching to improve a child’s
sitting abilities
Increase walking practice to improve
muscle strength
Initiate a buddy system at school so that
child can keep up with peers and
socialize
 Influence of context on outcomes
 Therapists must acknowledge that a person’s functional motor abilities are
influenced by context

 For example,

A child may be able to improve his or her ability to climb the stationary stairs in the
physiotherapy department, but he or she may not be able to extrapolate this
improvement to the stairs in school due to have a different rise and the skills
required to navigate among other students crowding the stairs
 Intervention

 A similar matrix may also be very useful in clinical practice to assist therapists to reflect
on the assumptions being made in clinical practice about what kind of intervention they
are using and what the expected outcome will be

 If outcomes are not as expected, identification of the reasons also becomes simpler.

 E.g. A child is discharged form active therapy with a clear home programme for
maintenance of function. The child returns after 3 months with 80% loss of skills gained
in therapy prior to discharge. It might become necessary to adopt a strategy of
continuous therapy at intervals to avoid such an outcome
 Using matrix system
 ICF as a ‘‘guiding system’’ - ICF provides an opportunity for therapists to
consider many intervention ‘‘points of entry’’ when making therapy plans

 ICF when used with CBR matrix gives a long term view of goal setting needs
 Using matrix system
 Outcome measures are used to find out whether the therapy gains are meaningful to
patients. Eg. We might notice an improvement in ROM of 15 degrees in shoulder
abduction

 The patient’s goal was not Body Function but activity of doing her hair

 If this aspect is not evaluated using an outcome measure, management may appear to
be unsatisfactory

 Choice of outcome measure must consider which domain is important to the patient
 Mapping outcomes
 ICF has been used in rehabilitation is as a tool to categorize outcome
measures
Body structure and function Activity Participation
Range of motion (Goniometry ) GMFM CHIEF
Muscle strength (Dynamometer) PEDI Life H

Endurance (functional testing) EVGS

Pain FMS
 Changes in management strategies
 ICF helps to modify strategies based on patient’s evolving needs
 Walk being the same construct has different meanings and requirements in the
3 domains

Construct Domain
E.g. A child with CP- initial expectation is to walk Body Functions
Once achieved walk to the bathroom Activity
Once achieved walk in school Participation
Gait training would have started with a walker in the gym - (10ft) Body functions
Walking endurance to cover 5 m Activity
Walking with crutches on different surfaces for school 50m Participation
ICF Core sets
 Comprehensive ICF Core Set –includes spectrum of typical problems that
persons with specific health condition may face; allows thorough and
interdisciplinary assessment.
 Brief ICF Core Set –is derived from Comprehensive Core set, used when
brief assessment of functioning is necessary; for describing functioning
and disability in clinical and epidemiological studies.
 Generic Core Set –important for health statistics and public health, can be
part of patient`s medical history.
ICF Core sets
 Core Sets assists in evaluation of the condition

 Support the interdisciplinary, comprehensive assessment of functioning

 Core-sets developed for various health conditions

ICF Core sets
Follow up plan
 Most people coming to PT will have needs even after discharge

 ICF core sets can act as a guiding framework to plan surveillance

programs, follow up etc

 Core sets for CP list pain. This is normally not a focus of PT but something
to be considered during surveillance programs
Educational strategies
 Patient and caregiver education programs can be made more focussed
using ICF domains and core sets

 ICF can be used to develop and structure a patient education program

targeting to enhance patients perceived self-efficacy in relation to their
functioning
Brunani, 2015
 Checklist
 Who needs treatment and why?
 What are the expected outcomes of intervention?
 How should outcomes be measured and documented?
 What intervention, instructions, services, and number of visits are necessary to meet
these outcomes?
 How should the patient and caregivers be included in the decision making process?
 How should the success of the intervention and cost-effectiveness be evaluated?
 Are referrals needed for other health care services and screenings?
 When should we stop therapy?
Forward reasoning, or pattern recognition,
often is used when identifying salient
qualitative information

Steiner, 2002
 How does ICF fit in clinical reasoning
 Knowledge and psychomotor ability, including observational analysis and
interviewing skills , are important in the development of higher-level skill
demonstrative of expert practice

 Clinical matrix based on ICF helps in forward reasoning, deductive or backward

reasoning, concept mapping, evidence appraisal, and interactive collaboration with
the patient and family are important strategies for clinical decision making
How does ICF fit in clinical reasoning

Frew, 2008
 How does ICF fit in clinical reasoning
 Scientific reasoning and the Body Structures and Functions Dynamic

 Narrative Reasoning and the Activities, Participation and Contextual Factors Dynamic

 Pragmatic and Ethical Reasoning and the Contextual Factors Dynamic

How does ICF fit in clinical reasoning

Frew, 2008
How does ICF fit in clinical reasoning

Frew, 2008
How does ICF fit in clinical reasoning

Frew, 2008
How does ICF fit in clinical reasoning

Frew, 2008
 How does ICF compare to traditional methods
Method Value
ICF Greater emphasis on
functioning and therefore
easier to set goals for
activities & participation
and acknowledge CF
Emphasis on AT and
interdisciplinary care
Traditional diff.dx Puts emphasis on pattern
recognition and is very
useful for cold
orthopaedics
Emphasises the medical
model and hence may be
easier to identify red flags
Limitations
May not hone skills of
pattern recognition
Function is the focus and
hence certain methods
aimed at acquisition of lost
skills may be missed
Limited use when diagnosis
is known and focus is
activity/ function
May waste time in attempts
to regain lost function and
may approach rehabilitation
in a hierarchical manner
 Documentation through sources
 ICF guides assessments of functioning in primary environments (e.g., home, school,
and community)

Defining the purpose Quantification

Forms of assessment for obtaining
of assessment with and coding with the
evidence
reference universal qualifier
How does the child with Standardized and criterion referenced Standard scores
CP’s mind and body measures of cognition, perception, - Percentile scores and ranks
function? attention, sensation - Descriptive terms
- Tests of vision and audition - Ratings based on clinical
- Physical measurement judgment
- Laboratory measures
 Documentation through sources
 ICF guides assessments of functioning in primary environments (e.g., home, school,
and community)

Defining the purpose Quantification

Forms of assessment for obtaining
of assessment with and coding with the
evidence
reference universal qualifier
What barriers / Normative and criterion referenced Standard scores
facilitators impact Measures of physical, social, and - Percentile scores and ranks
functioning in the child’s attitudinal environments - Self-, - Descriptive terms
primary teacher-, parent-report of environment - Ratings based on clinical
environments? - Observation of person/environment judgment
interaction
- Photographic, audio, & video
Documentation
Documentation – interdisciplinary
 Summary

 Therapy aims at addressing issues important to the patient/ client

 This calls for strong scientific knowledge to set meaningful and achievable
goals and plan evidence based interventions
 Requires a strong engagement with the patient and her/his personal
characteristics in order to reach a clinical hypothesis, confirm the hypothesis,
choose sensitive and meaningful measures, plan and execute care
 We mostly work backwards from activity to BS&F. Hence strong skills of
observation and “hearing” are required.
 ICF framework is a good method to organise the processes.
Thank you