Editorial 195
What is next for ICF? Seija Talo International Journal of Rehabilitation Research 2014, 37:195–196
Received 5 May 2014 Accepted 26 May 2014
Medical Department, University of Turku, Turku, Finland Correspondence to Seija Talo, PhD, Koivuharjunk.25, 20660 Littoinen, Finland
When WHO’s International Classification of Functioning, Disability and Health (ICF) was established at the beginning of the new millennium (WHO, 2001), new definitions for ‘functioning’ and ‘disability’ had already been sought for decades. In addition to patients with disabilities themselves, this paradigm change was awaited by different stakeholders – from grass-root workers to governmental decision makers, especially in the social and healthcare field. It was realized over time that unified functional language is needed for human-rights-based equal responding to benefit claims not only in the healthcare field but in relation to well-being-related policy making in general. Accurate ICF definitions with unified linguistic terms were expected to reorganize the content of functioning and disability in the direction of breaking ‘inter-silo’ type of communication between different social systems and organizations. In other words, the ICF was expected to ground possibilities for horizontal interaction both within and between organizational silos, including all the relevant parties dealing with content and quality of service production, policies regulating service development and governmental acts monitoring the service production and delivery. Currently, as we are just about seeing the advantages of using the ICF in practice, one can rightfully ask whether we are happy now – having had the ICF with us for a short but intensive period worldwide. It is tempting to declaim that we are not nearly as happy as we should be and that we have not learnt the ‘non-silo’ communication well enough yet! It may be difficult for silo-experts to adjust their professional language to the ICF terms (Bruyère et al., 2005). Could we do something to facilitate this process? Without doubt, high-level efforts have been made through the years by WHO Collaboration Centers (WHO-CCs) to progressively develop ICF concepts and their implementation in practice. The question is how could the national stakeholders at different organizational levels be snatched to pilot and settle down the WHO-CC achievements? Honestly, the assurance of local, governmental and legal systems on the power of the ICF to facilitate decision-making in different policy fields may be the most difficult and time-consuming task in implementation of the ICF. It is believed that only solid ICF knowledge and its common, assertive use can be expected to convince the national establishments. 0342-5282 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
This places a great strain on the ICF learners and those who attempt to implement ICF applications. Fortunately, many ICF courses at advanced levels are thriving in various countries. However, it might be wise if some very simple and popular topics could be highlighted within the ICF education: (1) ICF implementation might profit from learners’ belief that ICF has come to stay, just like the ICD disease classification has survived since its early roots until today (WHO, 1992). (2) ICF implementation might also profit if all learners adopted a temporary identity of an ICF student independent of professional status of one’s own: every ICF user has to learn the conceptual system of the ICF classification thoroughly by participating in ABC-schools, seminars and workshops or by selflearning over the internet. Today, this should be easy because numerous innovative learning methods and teaching strategies to master ICF are increasingly being developed and applied in different countries worldwide (Anttila et al., 2013; WHO, 2013). (3) Next, ICF implementation might profit from learners’ participation in international linking courses arranged by responsible organizers to guarantee the unified results for linking, mapping or bridging of functional concepts in existing measurement instruments and techniques (interviews, questionnaires, surveys, tests, devices, etc.) to ICF functional concepts (Cieza et al., 2005). Unification of linking strategies is important because considerably differing opinions may exist especially in relation to new developments, such as ICF-linking of contextual personal factors, the domains of which are not yet listed in the ICF (Grotkamp et al., 2012). (4) Further, ICF implementation might profit from arranging noticeable national and international forums by responsible organizers to communicate about the utmost goal of functional assessment in general, that is the quantification of functional level. The conceptual breakthrough of the ICF is not enough, even though the mastering of concepts guarantees that we are on a solid base to develop the techniques and strategies for functional level measurement. DOI: 10.1097/MRR.0000000000000067
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
196 International Journal of Rehabilitation Research 2014, Vol 37 No 3
In relation to the fourth step mentioned above, one can ask how far have we progressed in the quantification of functioning in ICF terms for clinical and other purposes since 2001? For example, when evaluating the pros and cons of strategies such as checklists (WHO, 2002) and core sets (Bickenbach et al., 2012), it should be kept in mind that mere application of checklists and core sets without using other complementary measurement aids ruins the original ICF philosophy of free individual variation of meaningful elements in an individual’s functional profile. Checklists shorten the list of 1424 possible ICF categories for functional resources and disabilities without knowing whether the most important domains and categories from the ‘person-point-of-view’ have been dropped. Core sets, in turn, reject the principle of client-centeredness by stating what is meaningful for the patient, not for a person. This criticism is in relation to current advanced personalized medicine tailoring drugs to fit the patient’s genetic disposition to avoid risky side effects. Personalized medicine promises to offer the right treatment for the right person at the right time (Katsios and Roukos, 2010). Why would the same principle not play a primary role in regulating the most successful rehabilitation for an individual person in the context of his/her whole life? Therefore, these facts are worthy of high-profile discussions despite the fact that checklists and core sets can be the most important starting points for functional assessment. It may seem that discussing specific strategies to quantify an individual functional level is still far away from the more pressing need to learn about the ICF and its implementation. Nevertheless, one example can be mentioned here: the so-called ‘BPS-ICF model for assessment and promotion of functioning’ (Talo et al., 1996, 2009) has been developed by a multiprofessional team in Finland over the decades of ICF revision work to advance systematic and standard strategies for bio-psycho-social measurement of functioning and disabilities. The main characteristic of the model is that it links the functional measurement data not only to the ICF categories but also to their measurement angle from the physical, psychological or social point of view (BPS approach). This reminds us not to point to personal characteristics alone as being responsible for the level of individual functioning: environmental social context also has a lot to do with it. It should be noted that the BPS approach reorganizes the ICF categories for measurement purposes only, without altering the ICF structure and content as a conceptual classification. The model is called the ‘person-centred strategy’ because the BPS-ICF functional profile is determined by person/expert co-operation to be the basis for functional/well-being promotion plan, also constructed by means of person/expert co-operation. When made, the plan should be forwarded to the casemanagement expert controlling the enforcement of the promotion plan in the client’s living surrounding (Klockmo et al., 2014). In an ideal society with an ideal
social and healthcare system, the construction of the biopsycho-social functional profile should commence whenever an individual and personnel of any organization responsible for an individual’s well-being encounter a problem in relation to the experienced/observed health/ functioning/well-being. (An article on the implementation strategies for the ICF according to the BPS principle is in preparation.) To summarize, plenty of room for innovations still exists for ICF implementation. More importantly, after witnessing the advancements since 2001, one can expect the innovations to continue. At another level of importance, the issue is how and by whom these innovative developments should be evaluated for their possible piloting and eventual implementation in real-life practice. The innovators, developers and researchers may not be able to shout their important messages loud enough for national establishments to hear, not even the messages that do not fight towards human rights but defend them. We might have to learn more explosive strategies to make mass media more curious about the bio-psycho-social wellbeing of citizens.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Anttila HK, Jeglinsky I, Kontu EK, Koskinen S, Musikka-Siirtola M, Nurmi-Koikkalainen P, et al. (2013). Start-up on ICF learning network in Finland (abstract). 12th Congress of European Forum for Research in Rehabilitation, 11–14 September, Istanbul, Turkey. Bickenbach J, Cieza A, Rauch A, Stucki G (2012). ICF core sets, manual for clinical practice. Toronto: Hogrefe Publishing. Bruyère S, VanLooy S, Peterson D (2005). The International Classification of Functioning, Disability and Health (ICF): contemporary literature overview. Rehabil Psychol 50:103–104. Cieza A, Geyh S, Chatterji S, Kostanjsek N, Ustun B, Stucki G (2005). ICF linking rules: an update based on lessons learned. J Rehabil Med 37:212–218. Grotkamp SL, Cibis WM, Nuhtern EAM, von Mittelstaedt G, Seger WKF (2012). Personal factors in the International Classification of Functioning, Disabilities and Health: prospective evidence. Aust J Rehabil Counsel 18:1–24. Katsios C, Roukos DH (2010). Individual genomes and personalized medicine: life diversity and complexity. Personalized Medicine 7:347–350. Klockmo C, Marnetoft SU, Selander J, Nordenmark M (2014). Important components to create personal working alliances with clients in the mental health sector to support the recovery process. Int J Rehabil Res 37:40–47. Talo S, Rytökoski U, Hämäläinen A, Kallio V (1996). The biopsychosocial disease consequence model in rehabilitation: model development in the Finnish ‘work hardening’ programme for chronic pain. Int J Rehabil Res 19:93–109. Talo S, Rytökoski U, Hämäläinen A (2009). Educational program for quantification of functional profile by multiprofessional measurement of ICF-concepts. In: Fazekas G, Burger H, Harth A, Vilks A, editors. Proceedings of the 10th Congress of the European Federation for Research in Rehabilitation; 09–12 September 2009; Riga, Latvia. London: Wolters Kluwer: Lippincott Williams & Wilkins; p. S67. WHO (1992). International statistical classification of diseases and related health problems, ICD-10. Geneva: WHO. WHO (2001). International Classification of Functioning, Disability and Health: ICF. Geneva: WHO. WHO (2002). The ICF checklist: development and application (document WHO/HFS/CAS/C/02.95). Geneva: WHO. WHO (2013). WHO-FIC Network Annual Meeting 2013; 12–18 October 2013; Beijing, People’s Republic of China. Available at: http://apps.who.int/ classifications/network/meeting2013/en.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
What is next for ICF? Seija Talo International Journal of Rehabilitation Research 2014, 37:195–196
Received 5 May 2014 Accepted 26 May 2014
Medical Department, University of Turku, Turku, Finland Correspondence to Seija Talo, PhD, Koivuharjunk.25, 20660 Littoinen, Finland
When WHO’s International Classification of Functioning, Disability and Health (ICF) was established at the beginning of the new millennium (WHO, 2001), new definitions for ‘functioning’ and ‘disability’ had already been sought for decades. In addition to patients with disabilities themselves, this paradigm change was awaited by different stakeholders – from grass-root workers to governmental decision makers, especially in the social and healthcare field. It was realized over time that unified functional language is needed for human-rights-based equal responding to benefit claims not only in the healthcare field but in relation to well-being-related policy making in general. Accurate ICF definitions with unified linguistic terms were expected to reorganize the content of functioning and disability in the direction of breaking ‘inter-silo’ type of communication between different social systems and organizations. In other words, the ICF was expected to ground possibilities for horizontal interaction both within and between organizational silos, including all the relevant parties dealing with content and quality of service production, policies regulating service development and governmental acts monitoring the service production and delivery. Currently, as we are just about seeing the advantages of using the ICF in practice, one can rightfully ask whether we are happy now – having had the ICF with us for a short but intensive period worldwide. It is tempting to declaim that we are not nearly as happy as we should be and that we have not learnt the ‘non-silo’ communication well enough yet! It may be difficult for silo-experts to adjust their professional language to the ICF terms (Bruyère et al., 2005). Could we do something to facilitate this process? Without doubt, high-level efforts have been made through the years by WHO Collaboration Centers (WHO-CCs) to progressively develop ICF concepts and their implementation in practice. The question is how could the national stakeholders at different organizational levels be snatched to pilot and settle down the WHO-CC achievements? Honestly, the assurance of local, governmental and legal systems on the power of the ICF to facilitate decision-making in different policy fields may be the most difficult and time-consuming task in implementation of the ICF. It is believed that only solid ICF knowledge and its common, assertive use can be expected to convince the national establishments. 0342-5282 © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
This places a great strain on the ICF learners and those who attempt to implement ICF applications. Fortunately, many ICF courses at advanced levels are thriving in various countries. However, it might be wise if some very simple and popular topics could be highlighted within the ICF education: (1) ICF implementation might profit from learners’ belief that ICF has come to stay, just like the ICD disease classification has survived since its early roots until today (WHO, 1992). (2) ICF implementation might also profit if all learners adopted a temporary identity of an ICF student independent of professional status of one’s own: every ICF user has to learn the conceptual system of the ICF classification thoroughly by participating in ABC-schools, seminars and workshops or by selflearning over the internet. Today, this should be easy because numerous innovative learning methods and teaching strategies to master ICF are increasingly being developed and applied in different countries worldwide (Anttila et al., 2013; WHO, 2013). (3) Next, ICF implementation might profit from learners’ participation in international linking courses arranged by responsible organizers to guarantee the unified results for linking, mapping or bridging of functional concepts in existing measurement instruments and techniques (interviews, questionnaires, surveys, tests, devices, etc.) to ICF functional concepts (Cieza et al., 2005). Unification of linking strategies is important because considerably differing opinions may exist especially in relation to new developments, such as ICF-linking of contextual personal factors, the domains of which are not yet listed in the ICF (Grotkamp et al., 2012). (4) Further, ICF implementation might profit from arranging noticeable national and international forums by responsible organizers to communicate about the utmost goal of functional assessment in general, that is the quantification of functional level. The conceptual breakthrough of the ICF is not enough, even though the mastering of concepts guarantees that we are on a solid base to develop the techniques and strategies for functional level measurement. DOI: 10.1097/MRR.0000000000000067
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
196 International Journal of Rehabilitation Research 2014, Vol 37 No 3
In relation to the fourth step mentioned above, one can ask how far have we progressed in the quantification of functioning in ICF terms for clinical and other purposes since 2001? For example, when evaluating the pros and cons of strategies such as checklists (WHO, 2002) and core sets (Bickenbach et al., 2012), it should be kept in mind that mere application of checklists and core sets without using other complementary measurement aids ruins the original ICF philosophy of free individual variation of meaningful elements in an individual’s functional profile. Checklists shorten the list of 1424 possible ICF categories for functional resources and disabilities without knowing whether the most important domains and categories from the ‘person-point-of-view’ have been dropped. Core sets, in turn, reject the principle of client-centeredness by stating what is meaningful for the patient, not for a person. This criticism is in relation to current advanced personalized medicine tailoring drugs to fit the patient’s genetic disposition to avoid risky side effects. Personalized medicine promises to offer the right treatment for the right person at the right time (Katsios and Roukos, 2010). Why would the same principle not play a primary role in regulating the most successful rehabilitation for an individual person in the context of his/her whole life? Therefore, these facts are worthy of high-profile discussions despite the fact that checklists and core sets can be the most important starting points for functional assessment. It may seem that discussing specific strategies to quantify an individual functional level is still far away from the more pressing need to learn about the ICF and its implementation. Nevertheless, one example can be mentioned here: the so-called ‘BPS-ICF model for assessment and promotion of functioning’ (Talo et al., 1996, 2009) has been developed by a multiprofessional team in Finland over the decades of ICF revision work to advance systematic and standard strategies for bio-psycho-social measurement of functioning and disabilities. The main characteristic of the model is that it links the functional measurement data not only to the ICF categories but also to their measurement angle from the physical, psychological or social point of view (BPS approach). This reminds us not to point to personal characteristics alone as being responsible for the level of individual functioning: environmental social context also has a lot to do with it. It should be noted that the BPS approach reorganizes the ICF categories for measurement purposes only, without altering the ICF structure and content as a conceptual classification. The model is called the ‘person-centred strategy’ because the BPS-ICF functional profile is determined by person/expert co-operation to be the basis for functional/well-being promotion plan, also constructed by means of person/expert co-operation. When made, the plan should be forwarded to the casemanagement expert controlling the enforcement of the promotion plan in the client’s living surrounding (Klockmo et al., 2014). In an ideal society with an ideal
social and healthcare system, the construction of the biopsycho-social functional profile should commence whenever an individual and personnel of any organization responsible for an individual’s well-being encounter a problem in relation to the experienced/observed health/ functioning/well-being. (An article on the implementation strategies for the ICF according to the BPS principle is in preparation.) To summarize, plenty of room for innovations still exists for ICF implementation. More importantly, after witnessing the advancements since 2001, one can expect the innovations to continue. At another level of importance, the issue is how and by whom these innovative developments should be evaluated for their possible piloting and eventual implementation in real-life practice. The innovators, developers and researchers may not be able to shout their important messages loud enough for national establishments to hear, not even the messages that do not fight towards human rights but defend them. We might have to learn more explosive strategies to make mass media more curious about the bio-psycho-social wellbeing of citizens.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References Anttila HK, Jeglinsky I, Kontu EK, Koskinen S, Musikka-Siirtola M, Nurmi-Koikkalainen P, et al. (2013). Start-up on ICF learning network in Finland (abstract). 12th Congress of European Forum for Research in Rehabilitation, 11–14 September, Istanbul, Turkey. Bickenbach J, Cieza A, Rauch A, Stucki G (2012). ICF core sets, manual for clinical practice. Toronto: Hogrefe Publishing. Bruyère S, VanLooy S, Peterson D (2005). The International Classification of Functioning, Disability and Health (ICF): contemporary literature overview. Rehabil Psychol 50:103–104. Cieza A, Geyh S, Chatterji S, Kostanjsek N, Ustun B, Stucki G (2005). ICF linking rules: an update based on lessons learned. J Rehabil Med 37:212–218. Grotkamp SL, Cibis WM, Nuhtern EAM, von Mittelstaedt G, Seger WKF (2012). Personal factors in the International Classification of Functioning, Disabilities and Health: prospective evidence. Aust J Rehabil Counsel 18:1–24. Katsios C, Roukos DH (2010). Individual genomes and personalized medicine: life diversity and complexity. Personalized Medicine 7:347–350. Klockmo C, Marnetoft SU, Selander J, Nordenmark M (2014). Important components to create personal working alliances with clients in the mental health sector to support the recovery process. Int J Rehabil Res 37:40–47. Talo S, Rytökoski U, Hämäläinen A, Kallio V (1996). The biopsychosocial disease consequence model in rehabilitation: model development in the Finnish ‘work hardening’ programme for chronic pain. Int J Rehabil Res 19:93–109. Talo S, Rytökoski U, Hämäläinen A (2009). Educational program for quantification of functional profile by multiprofessional measurement of ICF-concepts. In: Fazekas G, Burger H, Harth A, Vilks A, editors. Proceedings of the 10th Congress of the European Federation for Research in Rehabilitation; 09–12 September 2009; Riga, Latvia. London: Wolters Kluwer: Lippincott Williams & Wilkins; p. S67. WHO (1992). International statistical classification of diseases and related health problems, ICD-10. Geneva: WHO. WHO (2001). International Classification of Functioning, Disability and Health: ICF. Geneva: WHO. WHO (2002). The ICF checklist: development and application (document WHO/HFS/CAS/C/02.95). Geneva: WHO. WHO (2013). WHO-FIC Network Annual Meeting 2013; 12–18 October 2013; Beijing, People’s Republic of China. Available at: http://apps.who.int/ classifications/network/meeting2013/en.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
