14. Strategies For Filling In the ICF/ NDTA Enablement Model

There are hundreds of medical reports in Kiyoshi’s file.   In addition to oligoarticular juvenile idiopathic arthritis (JIA)  he has uveitis and a seizure disorder.  Kiyoshi has severe pain, joint contractures and difficulty moving around.  Medications are not controlling the inflammation, there have been more seizures lately and his foot orthotics are too small.    How do you begin physical therapy decision-making with a child this complex?

The International Classification of Functioning  (ICF) conceptual framework allows you to apply your knowledge  and skills to challenging situations.  It will take a while to sort information into proper categories and edit. However, once this is complete, connections become clear and sound clinical decision-making will follow.    The question I get asked most often about the ICF is , “where do you start?”.  This post will guide you as you fill in the ICF/NDTA Enablement Model categories for the first time.

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  1. CHOOSING WHAT IS IMPORTANT IN EACH DOMAIN:
    • More and more diagnoses have their own specific ICF Core Sets.  These sets tell you what is important to measure and include in each domain.  You can choose the assessment you want to measure and document.
  2. NOT SURE WHAT ASSESSMENTS TO USE?
    • The APTA Section on Pediatrics has a wonderful list of PT assessment tools categorized by ICF domain.
  3. IMPAIRMENT: Take a breath and get started listing impairments.
    • Review medical reports: neuro, ortho, GI, pulmonology, cardiology, rheumatology.   Document anything having to do with a body system (within reason relating to PT).   This way, you will know a lot about your patient before you meet.   In Kiyoshi’s case, the seizure disorder will not be a surprise since that does not commonly go with juvenile arthritis.
    • Next, begin to fill in impairments that are neurological or musculoskeletal: specifics of tone, weakness, motor control, joint range or asymmetry.  Don’t forget balance, endurance and pain are also in this section.   You may use appropriate assessments to measure any of these in your session.
    • In addition, simply because it helps me,  I add surgeries that addressed impairments in body systems and their dates.  For instance:  Tethered cord: repaired 2/2014.
  4. ACTIVITY: Go to the standardized measure specific for your patient’s diagnosis.
    • In PT, this is often the  GMFM,  or any other standardized measure of activity.    Independent activities can go into the activity section; activities that require assistance go into the activity limitations section.
    • If you start thinking about quality, move to #4!  This section is only about what the person can or can’t do.  If they are leaning to the left and the right hip is adducted and internally rotated during gait discuss it in the movement section.
  5. PARTICIPATION:
    • Think of the subjective notes you have written in the past.
    • Did your patient tell you all about their Disneyland trip recently?  The aquarium?  A movie theater in the city hat had an inaccessible bathroom?  A parade?  A sleep-over? A field trip?  Did they mention they can’t access the track to participate in PE with the rest of their class?  You will recall if you think back to conversations.
    • Also, think of participation in the home:  tubs, stairs, meals, getting to an upstairs room.  How are these things going?  Think of school, community, community resources.
    • What is happening for recreation?  Challenger baseball?  Hippotherapy?  Shooting hoops in the driveway?
    • Sometimes the Canadian Occupational Measure is helpful if you are really stuck for participation ideas.
    • I began to understand participation on a whole new level after filling out a Participation and Environment Measure for Children and Youth (PEM-CY) as a parent.
  6. MOVEMENT:
    • Now you are free to discuss  quality of movement; visualize your patient as they move and write your observations down in this category.   That perpetual trunk lean to the left goes here.
  7. EQUIPMENT/ENVIRONMENT:
    • What equipment supports activity and participation?  What is needed?
  8. PERSONAL FACTORS:
    • Take a moment to think about some personal factors affecting your patient. I don’t write these down, but I do think about them;  I often address informally by suggesting resources.
  9. THINK ABOUT RELATIONSHIPS:
    • Now that your domains are all filled out, look them over and ask some questions about relationships.
    • Make sure you haven’t repeated yourself in one domain and that you haven’t put the same information into several domains.
    • Ask yourself how impairment relates to activity and activity to participation.  Participation can address impairments too.
    • Realize how certain postures and movement quality are present throughout every position, every activity. (like the lean to the left, in sitting, standing, walking)
    • Finally, how does equipment support participation?
  10. THINK ABOUT GOALS:
    • Set some goals from the activity limitation section.
    • Motivate the child and parents to increase participation opportunities.
    • Collaborate with doctors and other professionals to address  impairments that limit activities.
    • Use the ICF as a tool to bring together the child’s team.

Have fun and be patient with yourself; it takes a while to master the use of this conceptual framework.   It can stimulate critical thinking and draw out ideas and underlying presumptions, much as the Socratic method in teaching.     When each discipline, the child and the child’s parents contribute, this collaboration stimulates an incredible amount of learning and discussion, not to mention great outcomes.

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