DEFINITIONS AND

LEVELS OF
CLASSIFICATION IN
Seminar by: Nishanthgowda H L
ICF
Moderator: Mr. Shyam Krishnan
222138002 MPT (Community based rehabilitation)
1st Year MPT Assistant professor-selection grade
 CONTENTS
1. INTRODUCTION
2. THE WHO FAMILY OF INTERNATIONAL CLASSIFICATIONS
3. THE MODEL OF ICF
4. CONCEPTS OF FUNCTIONING AND DISABILITY
5. DEFINITIONS
6. THE QUALIFIERS
7. THE DOMAINS OF ICF
8. LEVEL ONE CLASSIFICATION
9. LEVEL TWO CLASSIFICATION
10. ICF CHECKLIST
11. ICF CASE EXAMPLES
12. REFERENCES
 INTRODUCTION
• The International Classification of Functioning, Disability and Health, known more commonly
as ICF, provides a standard language and framework for the description of health and health-
related states.
• Like the first version published by the World Health Organization for trial purposes in 1980,
ICF is a multipurpose classification intended for a wide range of uses in different sectors.
• It is a classification of health and health-related domains - domains that help us to describe
changes in body function and structure,
• In ICF, the term functioning refers to all body functions, activities and participation, while
disability is similarly an umbrella term for impairments, activity limitations and participation
restrictions. ICF also lists environmental factors that interact with all these components.
• ICF is WHO's framework for health and disability. It is the conceptual
basis for the definition, measurement and policy formulations for health
and disability.

• It is a universal classification of disability and health for use in health and

health related sectors.

• ICF therefore looks like a simple health classification, but it can be used
for a number of purposes. The most important is as a planning and policy
tool for decision-makers.
 THE WHO FAMILY OF
INTERNATIONAL CLASSIFICATIONS
• ICF belongs to the WHO family of international classifications, the best known member of
which is the ICD-10 (ICF 11NEW ONE CAME) (the International Statistical Classification of
Diseases and Related Health Problems).
• The ICD-10 and ICF are therefore complementary, and users are encouraged to use them
together to create a broader and more meaningful picture of the experience of health of
individuals and populations.
• Information on mortality (provided by ICD-10) and information about health and health-related
outcomes (provided by ICF) can be combined in summary measures of population health. In
short, ICD-10 is mainly used to classify causes of death, but ICF classifies health.
THE WHO FAMILY OF INTERNATIONAL
CLASSIFICATIONS
 THE MODEL OF ICF

• The medical model views disability as a feature of the person, directly

caused by disease, trauma or other health condition, which requires
medical care provided in the form of individual treatment by professionals.
• The social model of disability, on the other hand, sees disability as a
socialy created problem and not at all an attribute of an individual.
• On the social model, disability demands a political response, since the
problem is created by an unaccommodating physical environment brought
about by attitudes and other features of the social environment.
The Biopsychosocial Model
•Alternative to medical and social models.
•Complex interaction of biological, psychological, and social factors in combination
that play role in individual’s ability to function.
• This more useful model of disability might be called the biopsychosocial model.
• ICF provides, by this synthesis, a coherent view of different perspectives of health:
biological, individual and social. The following diagram is one representation of
the model of disability that is the basis for ICF.
 HOW IS THE ICF ORGANISED?
• ICF organizes information in two parts. Part 1 deals with functioning and disability while part
2 covers contextual factors. Each part has two components:
• Functioning and Disability:
o Body Functions and Body Structures
o Activities and Participation
• Contextual Factors:
o Environmental Factors
o Personal Factors
CONCEPTS OF FUNCTIONING AND DISABILITY
• As the diagram indicates, in ICF disability and functioning are viewed as outcomes of
interactions between health conditions (diseases, disorders and injuries) and contextual
factors.
• Among contextual factors are external environmental factors (for example, social attitudes,
architectural characteristics, legal and social structures, as well as climate, terrain and so
forth); and internal.
• personal factors, which include gender, age, coping styles, social background, education,
profession, past and current experience, overall behaviour pattern, character and other factors
that influence how disability is experienced by the individual.
• The diagram identifies the three levels of human functioning classified by
ICF: functioning at the level of body or body part, the whole person, and
the whole person in a social context. Disability therefore involves
dysfunctioning at one or more of these same levels: impairments, activity
limitations and participation restrictions. The formal definitions of these
components of ICF are provided in the box below.
 DEFINITIONS

• Functioning is an umbrella term for body functions, body structures, activities and
participation. It denotes the positive aspects of the interaction between an
individual (with a health condition) and that individual’s contextual factors
(environmental and personal factors).
• Disability is an umbrella term for impairments, activity limitations and
participation restrictions. It denotes the negative aspects of the interaction between
an individual (with a health condition) and that individual’s contextual factors
(environmental and personal factors).
• 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.
• Activity - The execution of a task or action by an individual.
• Participation - Involvement in a life situation.
• Activity limitations - Difficulties an individual may have in executing activities.

• Participation restrictions - Problems an individual may experience in

involvement in life situations.

• Environmental factors - 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.
 THE QUALIFIERS
• The list of domains in ICF becomes a classification when qualifiers are used.
• Qualifiers record the presence and severity of a problem in functioning at the body,
person and societal level.
• For the classifications of body function and structure, the primary qualifier indicates the
presence of an impairment and, on a five point scale, the degree of the impairment of
function or structure (no impairment, mild, moderate, severe and complete).
• In the case of the Activity and Participation list of domains, two important qualifiers are
provided. Together, these qualifiers enable the user to code essential information about
disability and health.
 PERFORMANCE QUALIFIER

• The Performance qualifier describes what an individual does in his or her

current environment.
• Since the current environment always includes the overall societal context,
performance can also be understood as "involvement in a life situation" or "the
lived experience" of people in their actual context.
• (The 'current environment' will be understood to include assistive devices or
personal assistance, whenever the individual actually uses them to perform actions
or tasks.)
 CAPACITY QUALIFIER
• The Capacity qualifier describes an individual’s ability to execute a task or an
action. This construct indicates the highest probable level of functioning of a
person in a given domain at a given moment.

• When a person has a capacity problem associated with a health condition,

therefore, that incapacity is a part of their state of health. To assess the full ability
of the individual, one would need to have a “standardized environment" to
neutralize the varying impact of different environments on the ability of the
individual.
• In practice, there are many possible environments that we could use for
this purpose.
• That is, a standardized environment might be:
(a) an actual environment commonly used for capacity assessment in test
settings;
(b) an assumed environment thought to have an uniform impact;
(c) an environment with precisely defined parameters based on extensive
scientific research.
• The Capacity qualifier assumes a 'naked person' assessment, that is, the person's
capacity without personal assistance or 12 the use of assistive devices.
• For assessment purposes, this environmental adjustment has to be the same for all
persons in all countries to allow for international comparisons.
• For precision and international comparability, features of the uniform or standard
environment can be coded using the Environmental Factors classification.
• If capacity is less than performance, then the person's current environment has
enabled him or her to perform better than what data about capacity would predict:
the environment has facilitated performance.

• On the other hand, if capacity is greater than performance, then some aspect of the
environment is a barrier to performance.

• The distinction between environmental ‘barriers’ and ‘facilitators’, as well as the

extent to which a environmental factor acts in one way or another, is captured by
the qualifier for coding Environmental Factors.
• Finally, an additional qualifier is available to supplement this information.
Both the Capacity and Performance qualifiers can further be used with and
without assistive devices or personal assistance.
• While neither devices nor personal assistance alter the impairments, they
may remove limitations on functioning in 13 specific domains.
• This type of coding is particularly useful to identify how much the
functioning of the individual would be limited without the assistive
devices.
 THE DOMAINS OF ICF

• The domains of ICF are arranged in a hierarchy (Chapter, second, third and fourth level
domains), which is reflected in the coding.
 LEVEL ONE CLASSIFICATION
LIST OF CHAPTER HEADINGS IN THE CLASSIFICATION

Function: Structure:
1. Mental Functions 1. Structure of the Nervous System
2. Sensory Functions and Pain 2. The Eye, Ear and Related Structures
Body
3. Voice and Speech Functions 3. Structures Involved in Voice and Speech
4. Functions of the Cardiovascular, 4. Structure of the Cardiovascular,
Haematological, Immunological and Immunological and Respiratory Systems
Respiratory Systems 5. Structures Related to the Digestive,
5. Functions of the Digestive, Metabolic, Metabolic and Endocrine Systems
Endocrine Systems 6. Structure Related to Genitourinary and
6. Genitourinary and Reproductive Reproductive Systems
Functions 7. Structure Related to Movement
7. Neuromusculoskeletal and Movement- 8. Skin and Related Structure
Related Functions
8. Functions af the Skin and Related
Structures
 Activities and Participation
1. Learning and Applying Knowledge
2. General Tasks and Demands
3. Communication
4. Mobility
5. Self Care
6. Domestic Life
7. Interpersonal Interactions and Relationships
8. Major Life Areas
9. Community, Social and Civic Life
 Environmental factors

1. Products and Technology

2. Natural Environment and Human-Made
Changes to Environment
3. Support and Relationships
4. Attitudes
5. Services, Systems and Policies
LEVEL TWO CLASSIFICATION
LIST OF CHAPTER HEADINGS IN THE CLASSIFICATIONS AND FIRST
BRANCHING LEVEL IN THE CLASSIFICATION.

BODY FUNCTIONS(b)

• Definitions: Body functions are the physiological functions of body systems

(including psychological functions).

• Impairments are problems in body function or structure as a significant deviation

or loss
 USING THE QUALIFIER FOR BODY
FUNCTIONS
• Body functions are coded with one qualifier that indicates the extent or magnitude of the
impairment. The presence of an impairment can be identified as a loss or lack, reduction,
addition or excess, or deviation.
• The impairment of a person with hemiparesis can be described with code b7302 Power of
muscles of one side of the body:

• Example: b167.3 to indicate a severe impairment in specific mental functions of languag

• The absence of an impairment (according to a predefined threshold level) is
indicated by the value “0” for the generic qualifier.
• For example: b7302.0 NO impairment in power of muscles of one side of body.

• If there is insufficient information to specify the severity of the impairment, the

value “8” should be used. For example, if a person’s health record states that the
person is suffering from weakness of the right side of the body without giving
further details, then the following code can be applied:

• b7302.8 Impairment of power of muscles of one side of body, not specified.

 QUALIFIER
• Generic qualifier with the negative scale, used to indicate the extent or magnitude of
an impairment:
• xxx.0 NO impairment (none, absent, negligible,… ) 0-4%
• xxx.1 MILD impairment (slight, low,…) 5-24 %
• xxx.2 MODERATE impairment (medium, fair,...) 25-49 %
• xxx.3 SEVERE impairment (high, extreme,…) 50-95 %
• xxx.4 COMPLETE impairment (total,…) 96-100 %
• xxx.8 not specified
• xxx.9 not applicable
 BODY STRUCTURES(S)
• Definitions: Body structures are anatomical parts of the body such as organs,
limbs and their components.

• Impairments are problems in body function or structure as a significant

deviation or loss.
First qualifier Extent of impairment Second qualifier Nature of impairment Third qualifier (suggested) Location of
impairment

0 no change in structure 0 more than one region

0 NO impairment
1 total absence 1 right
1 MILD impairment
2 partial absence 2 left
2 MODERATE impairment 3 additional part 3 both sides
3 SEVERE impairment 4 aberrant dimensions 4 front
4 COMPLETE impairment 5 discontinuity 5 back
8 not specified 6 deviating position 6 proximal
7 qualitative changes in 7 distal
9 not applicable
structure, including 8 not specified
accumulation of fluid
9 not applicable
8 not specified
9 not applicable
 USING QUALIFIERS FOR CODING BODY
STRUCTURES
Body structures are coded with three qualifiers. The first qualifier describes the
extent or magnitude of the impairment, the second qualifier is used to indicate the
nature of the change, and the third qualifier denotes the location of the impairment.

Example: s730.3 to indicate a severe impairment of the upper extremity

ACTIVITIES AND PARTICIPATION(D)

• Definitions: Activity is the execution of a task or action by an individual.

• Participation is involvement in a life situation.
• Activity limitations are difficulties an individual may have in executing
activities.
• Participation restrictions are problems an individual may experience in
involvement in life situations.
 QUALIFIERS
• The two qualifiers for the Activities and Participation component are the
performance qualifier and the capacity qualifier.
The performance qualifier describes what an individual does in his or her
current environment.
• The capacity qualifier describes an individual’s ability to execute a task or
an action.(WITHOUT ASSISTENCE)
• Both capacity and performance qualifiers can be used both with and
without assistive devices or personal assistance, and in accordance with
the following scale:
• Both capacity and performance qualifiers can be used both with and
without assistive devices or personal assistance, and in accordance with
the following scale:
• xxx.0 NO difficulty (none, absent, negligible,… ) 0-4 %
• xxx.1 MILD difficulty (slight, low,…) 5-24 %
• xxx.2 MODERATE difficulty (medium, fair,…) 25-49 %
• xxx.3 SEVERE difficulty (high, extreme, …) 50-95 %
• xxx.4 COMPLETE difficulty (total,…) 96-100 %
• xxx.8 not specified
• xxx.9 not applicable
USING THE CAPACITY AND PERFORMANCE
QUALIFIERS
• Activities and Participation is coded with two qualifiers: the performance
qualifier, which occupies the first digit position after the point, and the capacity
qualifier, which occupies the second digit position after the point. The code that
identifies the category from the Activities and Participation list and the two
qualifiers form the default information matrix
OPTIONAL QUALIFIERS
 ADDITIONAL QUALIFIERS
• The fifth digit position is reserved for qualifiers that may be developed in the
future, such as a qualifier for involvement or subjective satisfaction.
• Both capacity and performance qualifiers can further be used both with and
without assistive devices or personal assistance, and in accordance with the
following scale (where xxx stands for the second-level domain number):
• When to use the performance qualifier and the capacity qualifier Either qualifier

• may be used for each of the categories listed. But the information conveyed in each case is
different. When both qualifiers are used, the result is an aggregation of two constructs, i.e.:

• If only one qualifier is used, then the unused space should not be filled with .8 or .9, but left
blank, since both of these are true assessment values and would imply that the qualifier is
being used.

• Examples of the application of the two qualifiers

• d4500 Walking short distances

• d4500.3 _ moderate restriction in performance of walking short distances

• d4500._ 3 severe capacity limitation in walking short distances

Performance Capacity

Problem in the person’s current environment Limitation without assistance

Example: d5101.1_ to indicate mild difficulty

with bathing the whole body with the use of Example: d5101._2 to indicate moderate
assistive devices that are available to the difficulty with bathing the whole body;
person in his or her current environmen implies that there is moderate difficulty
without the use of assistive devices or
personal help
 ENVIRONMENTAL FACTORS (E)

• Definition: Environmental factors make up the physical, social and attitudinal

environment in which people live and conduct their lives.
• Environmental Factors is a component of Part 2 (Contextual factors) of the
classification. These factors must be considered for each component of
functioning and coded accordingly.
• Environmental factors are to be coded from the perspective of the person whose
situation is being described. For example, kerb cuts without textured paving may
be coded as a facilitator for a wheelchair user but as a barrier for a blind person.
• Example: e130.2 to indicate that products for education are a moderate barrier.

• Conversely, e130 +2 would indicate that products for education are a moderate
facilitator
 FIRST QUALIFIER
• The following is the negative and positive scale for the extent to which an environmental
factor acts as a barrier or a facilitator. A point or separator alone denotes a barrier, and the +
sign denotes a facilitator, as indicated below:
• xxx.0 NO barrier (none, absent, negligible,… ) 0-4%
• xxx.1 MILD barrier (slight, low,…) 5-24%
• xxx.2 MODERATE barrier (medium, fair,...) 25-49%
• xxx.3 SEVERE barrier (high, extreme, …) 50-95%
• xxx.4 COMPLETE barrier (total,…) 96-100%
• xxx+0 NO facilitator (none, absent, negligible,… ) 0-4%
• xxx+1 MILD facilitator (slight, low,…) 5-24%
• xxx+2 MODERATE facilitator (medium, fair,...) 25-49%
• xxx+3 SUBSTANTIAL facilitator (high, extreme, …) 50-95%
• xxx+4 COMPLETE facilitator (total,…) 96-100%
• xxx.8 barrier, not specified
• xxx+8 facilitator, not specified
• xxx.9 not applicable

Second qualifier: To be developed.

Barriers and facilitators to children with disability
Construct First qualifier First qualifier

Body Function Generic qualifier with the negative None

(b) scale used to indicate the extent or
magnitude of an impairment .

Example: b175.3 to indicate a severe

impairment in specific mental
functions of language
Body Structure Generic qualifier with the negative Used to indicate the nature of the change in the
respective body structure
(s) scale used to indicate the extent or 0 no change in structure
magnitude of an impairment 1 total absence
2 partial absence
3 additional part
Example: s730.3 to indicate a severe 4 aberrant dimensions
impairment of the upper extremity 5 discontinuity
6 deviating position
7 qualitative changes in structure, including
accumulation of fluid
8 not specified
9 not applicable
Example: s7300.32 to indicate the partial absence
of the upper extremity.
Construct First qualifier First qualifier
Activity & PERFORMANCE CAPACITY
Participation (d) Generic qualifier Generic qualifier
Problem in the person's current Limitation without assistance
environment
Example: d5101._2 to indicate moderate
Example: d5101.1_ to indicate mild difficulty with bathing the whole body
difficulty with bathing the whole body and implies that there is moderate
with the use of assistive devices that difficulty without the use of assistive
are available to the person in his or her devices or personal help.
current environment.
Environmental Generic qualifier, with negative and None
Factors (e) positive scale to denote extent of
barriers and facilitators respectively

Example: e145.2 to indicate that

products for education are a moderate
barrier. Conversely, e145+2 would
indicate that products for education are
a moderate facilitator
ICF CHECKLIST VERSION 2.1A,
CLINICIAN FORM FOR INTERNATIONAL
CLASSIFICATION OF FUNCTIONING, DISABILITY
AND HEALTH

icfchecklist.pdf
• Mrs T is a 57 year old woman who was diagnosed with relapsing remitting
multiple sclerosis 24 years ago. Seven years ago, her diagnosis was
adjusted to Secondary Progressive MS as the condition progressed
according to its natural history. In response to progressive lower extremity
weakness and disequilibrium, she was provided with a manual fixed frame
wheelchair four years ago. Using the ICF, Mrs T’s situation could be
summarized by the following schematic.
ICF CASE EXAMPLE –OVERVIEW
THE SS-QOL INSTRUMENT THE SS-QOL, AN INSTRUMENT DEVELOPED
TO MEASURE STROKE-SPECIFIC QUALITY OF LIFE

TABLE 2 STROKE-SPECIFIC QUALITY OF LIFE (SS-QOL) INSTRUMENT

LINKED WITH THE ICF CATEGORIES
• The WOMAC index is a three-dimensional, selfadministered, disease-
specific, health-status measure to investigate patient-relevant and clinically
important outcomes of therapies of OA of the lower extremities. It consists
of 24 items: five items are related to pain, two items to stiffness, and 17
items to physical function
 REFFERECES
• World Health Organization. International Classification of Functioning, Disability, and
Health: Children & Youth Version: ICF-CY. World Health Organization; 2007.
• Shields N, Synnot A. Perceived barriers and facilitators to participation in physical
activity for children with disability: a qualitative study. BMC pediatrics.
2016 Dec;16(1):1-0.
• Teixeira-Salmela LF, Neto MG, Magalhães LC, Lima RC, Faria CD. Content
comparisons of stroke-specific quality of life based upon the international classification
of functioning, disability, and health. Quality of Life Research. 2009 Aug;18:765-73
• Weigl M, Cieza A, Harder M, Geyh S, Amann E, Kostanjsek N, Stucki G. Linking
osteoarthritis-specific health-status measures to the International Classification of
Functioning, Disability, and Health (ICF). Osteoarthritis and Cartilage. 2003 Jul
1;11(7):519-23.
• How to use the ICF - A Practical Manual for using the International Classification of
Functioning, Disability and Health [Internet]. [cited 2023 Apr 16]. Available from:
https://www.who.int/publications/m/item/how-to-use-the-icf---a-practical-manual-for-using-th
e-international-classification-of-functioning-disability-and-health
• World Health Organization. Towards a common language for functioning, disability, and
health: ICF. The international classification of functioning, disability and health. 2002.
• ICF Checklist [Internet]. [cited 2023 Apr 16]. Available from:
https://www.who.int/publications/m/item/icf-checklist