293
Journal of Vestibular Research 23 (2013) 293–296 DOI 10.3233/VES-130486 IOS Press
Introduction to the international classification of functioning disability and health – ICF – in the context of vestibular rehabilitation Mariella Graziano Physiotherapist in the Community, 16 rue Boltgen, 4038 Esch-sur-Alzette, Luxembourg Tel.: +352 26 53 15 51; E-mail: [email protected]
Received 23 March 2013 Accepted 12 June 2013
Abstract. Vestibular rehabilitation focuses at decreasing the impact of symptoms, such as vertigo dizziness and imbalance have on people’s daily life and their role in society. The international Classification of Functioning Disability and Health – ICF offers a unified and standard language and framework for describing health and health related states. The ICF aims at facilitating communication information about health, like functioning and disability. For this purpose the ICF has a systematic coding scheme for health data with more than 1400 categories. The big number of categories is impractical to apply in a specific area like vestibular disorders. Therefore a narrowing down to the relevant categories in a comprehensive core set for vertigo (100 categories) and a brief core set (29 categories) were developed. The purpose of this article is to reflect on the potential use of ICF in vestibular rehabilitation. Keywords: Vertigo, dizziness, ICF, core sets, vestibular rehabilitation
1. Introduction Vertigo, dizziness and imbalance [2] are major symptoms of health conditions affecting the vestibular and central nervous system, which can result in physical and psychological problems, such as anxiety and avoidance behavior. The disturbances can be complex and may have serious consequences on the person’s independence, role in society and well-being. Traditionally the medical model concentrates on identifying the disease that causes the symptoms, without taking into account the impact the symptoms have on the person’s daily life and participation in society. Some people with unilateral vestibular loss after vestibular neuritis have no or nearly no symptoms and no significant disabilities whereas others are severely disabled [4]. A medical diagnosis as such, does not inform about this difference. Considering the patient’s perspective, goals and level of functioning are essential to plan and evalu-
ate rehabilitation programs. Several self-reported measures are available to evaluate different aspects of disability and functioning in people with vestibular disorders. Some examples of scales used in clinical practice and research are the Dizziness Handicap Inventory (DHI) [7], the Vertigo Handicap Questionnaire (VHQ) [9] and the Vestibular Disorders Activity of Daily Living Scale (VASL) [3]. The DHI is a 25 item questionnaire, which indicates the level of impairment felt by a patient with dizziness. It measures the emotional functional and physical impacts of dizziness on the person’s daily life. The VHQ is a 22-item questionnaire that measures the disabling consequences of vertigo on activities of daily living (ADL), social life, and leisure. The VADL evaluates self-perceived impairments in individuals with vestibular damage. It comprises 28 items, which examine the functional limitations of vestibular disorders on activities of daily life. The items are organized in three cat-
c 2013 – IOS Press and the authors. All rights reserved ISSN 0957-4271/13/$27.50
294
M. Graziano / Introduction to the international classification of functioning disability and health
Health condion (disorder or disease)
Body funcons (b) & Structures (s)
Acvies (a)
Parcipaon (p)
(limitaons)
(restricons)
(impairments)
Environmental Factors (e)
Personal factors
(Barrier /Facilitators) Fig. 1. Components of ICF (based on [8]). Category: b7100 1st level b7 indicates the component body function in chapter 7 – Neuromusculoskeletal and movementrelated functions 2nd level
b710 mobility of joints
3rd level
b7100 mobility of a single joint – functions of the range and ease of movement of one joint Fig. 2. Example of the concept categories.
egories: basic self-maintenance tasks, mobility skills, and higher-level or more socially complex tasks outside the home. These questionnaires measure slightly different aspects [1]. The DHI and VHQ are symptom specific questionnaires, whilst the DHI measures the impact of dizziness on the patient health related quality of life, the VHQ evaluates the effect of vertigo in daily functioning and the VADL focuses on the functional limitations of activities of daily living. Ideally there should be an instrument which takes into account all potential aspects of disability in vestibular patients which is universally accepted and used [5]. This could help clinicians, researchers, and policy makers, to evaluate treatment outcomes and to compare data from individuals and populations with vestibular disorders at a national and international level. The World Health Organization (WHO) identified the need for providing a classification with a coherent view of different perspectives of health, from biological, individual and social perspective, that will capture the person as a whole and monitor change through the entire intervention process. The International Classification of Functioning Disability and
Health – ICF was unanimously endorsed at the 54th World Health Assembly in May 2001 as the framework for describing and measuring health and disability [8]. The ICF is supposed to provide the structure for the optimal management of vestibular disorders considering the patient and different users perspectives. The concept of the ICF might one day also be used in vestibular rehabilitation.
2. The structure of the international classification of functioning disability and health – ICF The ICF consists of 2 parts, which are further subdivided into 2 components each. The first part deals with functioning and disability and the 2 components are: [1] body functions and structures and [2] activities and participation. The second part involves contextual factors that include environmental and personal factors [8] see Fig. 1. The ICF provides a systematic coding scheme for health data, with more than 1400 categories, which describe and classify health, functioning and disability. The ICF classification is hierarchically organized with increasing levels indicating increasing degree of detail. The coding system follows a pattern in which all categories start with a letter (b, s, d, or e) denoting one of the ICF components: (b), body functions, (s), body structures, (d), activities and participation and (e) environmental factor. Each letter is followed by a numeric code, which indicates the chapter number or first ICF level (one digit) followed by the second ICF level (2 digits) and sometimes followed by the third and fourth ICF levels (one digit each). See Fig. 2 as an example.
M. Graziano / Introduction to the international classification of functioning disability and health
295
Health condion Le vesbular neuris
Body funcons (b) b2401 - b2403 b770 - b1266 & Structures (s) s260 (impairments)
Acvies (a) (limitaons) d220, d640, d750, d910
Environmental Factors (e) e310 Barriers. Lives alone Facilitators. Help from family
Parcipaon (p) (restricons)
Personal factors: 75 years old woman, lives alone
Legend Body functions (b)
b2401 – dizziness, b2403 - Nausea associated with dizziness or vertigo, b770 – gait patterns functions, : b1266 - confidence
Structures (s)
s260- structure of inner ear
Activities and
d220 – undertaking multiple tasks, d640 - doing housework, d750- informal
participation (d)
relationships, d910- Community life, d920 –recreation and leisure
Environmental
e310 – immediate family
factors (e)
Fig. 3. Patient example in ICF categories.
To be able to use these categories at a practical level without losing the perspective of different users it was necessary to narrow down the number of categories to serve specific health conditions. To this purpose the ICF core set project was initiated in 2001. Core sets are a range of ICF categories which are meant to describe the most significant aspects of functioning, disability and environmental factors of a particular health condition and still could be used in different settings [5].
3. ICF core sets for vertigo and dizziness In this context an international standard (ICF core sets) was developed for patients with vertigo and dizziness to describe the impact of vestibular disorders has on functioning. The ICF core set for vertigo and dizziness was established as a consensus between experts in the field
and evidence from preparatory studies. It is designed to be used by therapists, nurses, physicians and other health professionals working in clinical settings and research [5]. It consists of a comprehensive ICF Core Set (100 categories) and a brief core set (29 categories). The comprehensive core set is meant to serve as a basis for assessment and documentation, mainly in the context of multidisciplinary care or advanced care planning, whilst the brief core set proposes a short list of categories intended to serve as the minimal standard for assessment and description of functioning and disability in clinical studies or in vestibular rehabilitation [5].
4. Example GM is a 75 year old lady, who lived alone fully independently with a good social life until she developed a
296
M. Graziano / Introduction to the international classification of functioning disability and health
sudden onset of severe dizziness and nausea during the night. For the following two weeks she stayed at home and a relative helped her with housework and shopping. She tried to do as much as she could on her own and slowly improved but not fully. She lost confidence and stopped going to the community center to meet friends. The family physician referred her for vestibular testing. She was diagnosed with incomplete right vestibular loss probably due to neuritis (in caloric test right hypofunction 60% and left directional preponderance 29%), GM was referred for Vestibular rehabilitation. The description of the patient in ICF language is illustrated in Fig. 3.
5. Conclusion The international classification of Functioning Disability and health – ICF intends to offer a universal language and a theoretical framework for the description of health and health related states that can be used for the content comparison process. The core set for vertigo, dizziness and balance identified the items from the whole ICF set, which are relevant for vestibular disorders. The core sets recognizes dimensions to describe functioning and disability in patients with vestibular conditions but, like the entire ICF, it does not represent a tool to measure (quantify) those dimensions. Those tools still need to be developed taking into account the core sets.
References [1] A.A. Alghwiri, G.F. Marchetti and S.L. Whitney, Content Comparison of Self-Report Measures Used in Vestibular Rehabilitation Based on the International Classification of Functioning, Disability and Health Physical Therapy 91 (2011), 1–12. [2] A. Bisdorff, M. Von Brevern, T. Lempert and D. NewmanToker, Classification of vestibular symptoms: Towards an international classification of vestibular disorders, J Vest Res 19 (2009), 1–13. [3] H.S. Cohen and K.T. Kimball, Development of the vestibular disorders activities of daily living scale, Arch Otolaryngol Head Neck Surg 126 (2000), 881–887. [4] F. Godemann, K. Siefert, M. Hantschke-Brüggemann, P. Neu, R. Seidl and A. Ströhle, What accounts for vertigo one year after neuritis vestibularis – anxiety or a dysfunctional vestibular organ, J Psychiatr Res 39 (2005), 529–534. [5] E. Grill, A. Bronstein, J. Furman, D.S. Zee and M. Müller, International Classification of Functioning, Disability and Health (ICF) Core Set for patients with vertigo, dizziness and balance disorders, Journal of Vestibular Research 22 (2012), 261–271. [6] E. Grill, T. Ewert, S. Chatterji, N. Kostanjsek and G. Stucki, ICF Core Sets development for the acute hospital and early post-acute rehabilitation facilities, Disabil Rehabil 27 (2005), 361–366. [7] G.P. Jacobson and C.W. Newman, The development of the Dizziness Handicap Inventory, Arch Otolaryngol Head Neck Surg 116 (1990), 424–427. [8] World Health Organisation (WHO) International Classification of Functioning, Disability and Health: ICF, WHO, Geneva, 2001. [9] L.Yardley and J. Putman, Quantitative analysis of factors contributing to handicap and distress in vertiginous patients: A questionnaire study, Clin Otolaryngol Allied Sci 17 (1992), 231–236.
Copyright of Journal of Vestibular Research: Equilibrium & Orientation is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Journal of Vestibular Research 23 (2013) 293–296 DOI 10.3233/VES-130486 IOS Press
Introduction to the international classification of functioning disability and health – ICF – in the context of vestibular rehabilitation Mariella Graziano Physiotherapist in the Community, 16 rue Boltgen, 4038 Esch-sur-Alzette, Luxembourg Tel.: +352 26 53 15 51; E-mail: [email protected]
Received 23 March 2013 Accepted 12 June 2013
Abstract. Vestibular rehabilitation focuses at decreasing the impact of symptoms, such as vertigo dizziness and imbalance have on people’s daily life and their role in society. The international Classification of Functioning Disability and Health – ICF offers a unified and standard language and framework for describing health and health related states. The ICF aims at facilitating communication information about health, like functioning and disability. For this purpose the ICF has a systematic coding scheme for health data with more than 1400 categories. The big number of categories is impractical to apply in a specific area like vestibular disorders. Therefore a narrowing down to the relevant categories in a comprehensive core set for vertigo (100 categories) and a brief core set (29 categories) were developed. The purpose of this article is to reflect on the potential use of ICF in vestibular rehabilitation. Keywords: Vertigo, dizziness, ICF, core sets, vestibular rehabilitation
1. Introduction Vertigo, dizziness and imbalance [2] are major symptoms of health conditions affecting the vestibular and central nervous system, which can result in physical and psychological problems, such as anxiety and avoidance behavior. The disturbances can be complex and may have serious consequences on the person’s independence, role in society and well-being. Traditionally the medical model concentrates on identifying the disease that causes the symptoms, without taking into account the impact the symptoms have on the person’s daily life and participation in society. Some people with unilateral vestibular loss after vestibular neuritis have no or nearly no symptoms and no significant disabilities whereas others are severely disabled [4]. A medical diagnosis as such, does not inform about this difference. Considering the patient’s perspective, goals and level of functioning are essential to plan and evalu-
ate rehabilitation programs. Several self-reported measures are available to evaluate different aspects of disability and functioning in people with vestibular disorders. Some examples of scales used in clinical practice and research are the Dizziness Handicap Inventory (DHI) [7], the Vertigo Handicap Questionnaire (VHQ) [9] and the Vestibular Disorders Activity of Daily Living Scale (VASL) [3]. The DHI is a 25 item questionnaire, which indicates the level of impairment felt by a patient with dizziness. It measures the emotional functional and physical impacts of dizziness on the person’s daily life. The VHQ is a 22-item questionnaire that measures the disabling consequences of vertigo on activities of daily living (ADL), social life, and leisure. The VADL evaluates self-perceived impairments in individuals with vestibular damage. It comprises 28 items, which examine the functional limitations of vestibular disorders on activities of daily life. The items are organized in three cat-
c 2013 – IOS Press and the authors. All rights reserved ISSN 0957-4271/13/$27.50
294
M. Graziano / Introduction to the international classification of functioning disability and health
Health condion (disorder or disease)
Body funcons (b) & Structures (s)
Acvies (a)
Parcipaon (p)
(limitaons)
(restricons)
(impairments)
Environmental Factors (e)
Personal factors
(Barrier /Facilitators) Fig. 1. Components of ICF (based on [8]). Category: b7100 1st level b7 indicates the component body function in chapter 7 – Neuromusculoskeletal and movementrelated functions 2nd level
b710 mobility of joints
3rd level
b7100 mobility of a single joint – functions of the range and ease of movement of one joint Fig. 2. Example of the concept categories.
egories: basic self-maintenance tasks, mobility skills, and higher-level or more socially complex tasks outside the home. These questionnaires measure slightly different aspects [1]. The DHI and VHQ are symptom specific questionnaires, whilst the DHI measures the impact of dizziness on the patient health related quality of life, the VHQ evaluates the effect of vertigo in daily functioning and the VADL focuses on the functional limitations of activities of daily living. Ideally there should be an instrument which takes into account all potential aspects of disability in vestibular patients which is universally accepted and used [5]. This could help clinicians, researchers, and policy makers, to evaluate treatment outcomes and to compare data from individuals and populations with vestibular disorders at a national and international level. The World Health Organization (WHO) identified the need for providing a classification with a coherent view of different perspectives of health, from biological, individual and social perspective, that will capture the person as a whole and monitor change through the entire intervention process. The International Classification of Functioning Disability and
Health – ICF was unanimously endorsed at the 54th World Health Assembly in May 2001 as the framework for describing and measuring health and disability [8]. The ICF is supposed to provide the structure for the optimal management of vestibular disorders considering the patient and different users perspectives. The concept of the ICF might one day also be used in vestibular rehabilitation.
2. The structure of the international classification of functioning disability and health – ICF The ICF consists of 2 parts, which are further subdivided into 2 components each. The first part deals with functioning and disability and the 2 components are: [1] body functions and structures and [2] activities and participation. The second part involves contextual factors that include environmental and personal factors [8] see Fig. 1. The ICF provides a systematic coding scheme for health data, with more than 1400 categories, which describe and classify health, functioning and disability. The ICF classification is hierarchically organized with increasing levels indicating increasing degree of detail. The coding system follows a pattern in which all categories start with a letter (b, s, d, or e) denoting one of the ICF components: (b), body functions, (s), body structures, (d), activities and participation and (e) environmental factor. Each letter is followed by a numeric code, which indicates the chapter number or first ICF level (one digit) followed by the second ICF level (2 digits) and sometimes followed by the third and fourth ICF levels (one digit each). See Fig. 2 as an example.
M. Graziano / Introduction to the international classification of functioning disability and health
295
Health condion Le vesbular neuris
Body funcons (b) b2401 - b2403 b770 - b1266 & Structures (s) s260 (impairments)
Acvies (a) (limitaons) d220, d640, d750, d910
Environmental Factors (e) e310 Barriers. Lives alone Facilitators. Help from family
Parcipaon (p) (restricons)
Personal factors: 75 years old woman, lives alone
Legend Body functions (b)
b2401 – dizziness, b2403 - Nausea associated with dizziness or vertigo, b770 – gait patterns functions, : b1266 - confidence
Structures (s)
s260- structure of inner ear
Activities and
d220 – undertaking multiple tasks, d640 - doing housework, d750- informal
participation (d)
relationships, d910- Community life, d920 –recreation and leisure
Environmental
e310 – immediate family
factors (e)
Fig. 3. Patient example in ICF categories.
To be able to use these categories at a practical level without losing the perspective of different users it was necessary to narrow down the number of categories to serve specific health conditions. To this purpose the ICF core set project was initiated in 2001. Core sets are a range of ICF categories which are meant to describe the most significant aspects of functioning, disability and environmental factors of a particular health condition and still could be used in different settings [5].
3. ICF core sets for vertigo and dizziness In this context an international standard (ICF core sets) was developed for patients with vertigo and dizziness to describe the impact of vestibular disorders has on functioning. The ICF core set for vertigo and dizziness was established as a consensus between experts in the field
and evidence from preparatory studies. It is designed to be used by therapists, nurses, physicians and other health professionals working in clinical settings and research [5]. It consists of a comprehensive ICF Core Set (100 categories) and a brief core set (29 categories). The comprehensive core set is meant to serve as a basis for assessment and documentation, mainly in the context of multidisciplinary care or advanced care planning, whilst the brief core set proposes a short list of categories intended to serve as the minimal standard for assessment and description of functioning and disability in clinical studies or in vestibular rehabilitation [5].
4. Example GM is a 75 year old lady, who lived alone fully independently with a good social life until she developed a
296
M. Graziano / Introduction to the international classification of functioning disability and health
sudden onset of severe dizziness and nausea during the night. For the following two weeks she stayed at home and a relative helped her with housework and shopping. She tried to do as much as she could on her own and slowly improved but not fully. She lost confidence and stopped going to the community center to meet friends. The family physician referred her for vestibular testing. She was diagnosed with incomplete right vestibular loss probably due to neuritis (in caloric test right hypofunction 60% and left directional preponderance 29%), GM was referred for Vestibular rehabilitation. The description of the patient in ICF language is illustrated in Fig. 3.
5. Conclusion The international classification of Functioning Disability and health – ICF intends to offer a universal language and a theoretical framework for the description of health and health related states that can be used for the content comparison process. The core set for vertigo, dizziness and balance identified the items from the whole ICF set, which are relevant for vestibular disorders. The core sets recognizes dimensions to describe functioning and disability in patients with vestibular conditions but, like the entire ICF, it does not represent a tool to measure (quantify) those dimensions. Those tools still need to be developed taking into account the core sets.
References [1] A.A. Alghwiri, G.F. Marchetti and S.L. Whitney, Content Comparison of Self-Report Measures Used in Vestibular Rehabilitation Based on the International Classification of Functioning, Disability and Health Physical Therapy 91 (2011), 1–12. [2] A. Bisdorff, M. Von Brevern, T. Lempert and D. NewmanToker, Classification of vestibular symptoms: Towards an international classification of vestibular disorders, J Vest Res 19 (2009), 1–13. [3] H.S. Cohen and K.T. Kimball, Development of the vestibular disorders activities of daily living scale, Arch Otolaryngol Head Neck Surg 126 (2000), 881–887. [4] F. Godemann, K. Siefert, M. Hantschke-Brüggemann, P. Neu, R. Seidl and A. Ströhle, What accounts for vertigo one year after neuritis vestibularis – anxiety or a dysfunctional vestibular organ, J Psychiatr Res 39 (2005), 529–534. [5] E. Grill, A. Bronstein, J. Furman, D.S. Zee and M. Müller, International Classification of Functioning, Disability and Health (ICF) Core Set for patients with vertigo, dizziness and balance disorders, Journal of Vestibular Research 22 (2012), 261–271. [6] E. Grill, T. Ewert, S. Chatterji, N. Kostanjsek and G. Stucki, ICF Core Sets development for the acute hospital and early post-acute rehabilitation facilities, Disabil Rehabil 27 (2005), 361–366. [7] G.P. Jacobson and C.W. Newman, The development of the Dizziness Handicap Inventory, Arch Otolaryngol Head Neck Surg 116 (1990), 424–427. [8] World Health Organisation (WHO) International Classification of Functioning, Disability and Health: ICF, WHO, Geneva, 2001. [9] L.Yardley and J. Putman, Quantitative analysis of factors contributing to handicap and distress in vertiginous patients: A questionnaire study, Clin Otolaryngol Allied Sci 17 (1992), 231–236.
Copyright of Journal of Vestibular Research: Equilibrium & Orientation is the property of IOS Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
