3.2. ICF and Clinical reasoning

The International Classification of Functioning, Disability and Health (ICF) is a framework for describing functioning and disability in relation to a health condition. It provides a common language and framework for documenting information on the functional changes associated with physical therapy interventions.

The ICF is a cornerstone of the Vietnamese rehabilitation guidelines and was introduced at the traumatic brain injury (TBI)  trainings as the overt basis for clinical decision making by physiotherapists. Within the clinical context, the ICF is intended for use in needs assessment, matching interventions to specific health states, rehabilitation and outcome evaluation.

This training course promotes the use of the ICF framework when assessing TBI survivors, encourages clinical reasoning and an improved holistic approach to identifying the patient’s problems in context. This, in turn, enables the therapist to plan a more appropriate intervention treatment, to the patient’s benefit.

The training of health professionals is complex as different cognitive and handling skills need to be taught and then applied in a clinical context. This clinical reasoning is one of the most difficult skills that physiotherapists have to utilize in everyday’s practice.

In the current training we introduce hypotheticodeductive reasoning strategy, which arises from a cognitive science perspective and focuses on the accessibility of stored knowledge in the therapist’s memory; and narrative reasoning, which is used to understand the patient’s experiences of their disability and their needs, as explained by them. In order to meet the needs of a patient, the therapist needs to know what the needs of the patient are, analyse these needs and the problems that are causing them, choose and apply suitable techniques, and assess whether or not the intervention has been effective.

Several models of the clinical process have been developed, but the most common model is a cyclical model in which assessment leads to appropriate goal setting and planning and to adequate treatment which then leads to changes in the condition of the patient. These changes need to be assessed and the cycle begins once more.

A useful framework to manage the information gained during patient assessment is the International Classification of Functioning, Disability and Health. The purpose of the ICF is to ‘provide a unified and standard language and framework for the description of health and health-related states’ (WHO, 2001). It defines health in terms of various health-related domains. These domains include areas of physiological function and anatomical structures, as well as actions, tasks and involvement in social situations. The domains are described from bodily, individual and societal perspectives within a given context. The ICF defines health in terms of health domains of well-being (e.g. walking, self-care abilities, communication, ability to learn, participation in social activities). The ICF can be used to describe all aspects of a patient’s functioning, disability and health. This information can be used to ensure a holistic approach to managing the patient.

The ICF is divided into two main categories: functioning and disability, and contextual factors. Non-problematic aspects of health are summarized under the umbrella term “functioning,” whereas “disability” serves as an umbrella term for impairment, activity limitation, or participation restriction.

Under functioning and disability, there are body functions and structure, which are organised according to body system and include changes in the physiological and anatomical structures. Also in this category are activities and participation, both from an individual and societal perspective. These are interpreted by capacity and performance ^[1]. The second category of the ICF classification includes environmental and personal factors. These can either facilitate or hinder functioning.

The ICF model can be used in conjunction with the rehab cycle as a clinical reasoning tool to guide physiotherapists in bridging the gap between cognitive knowledge and interaction in the clinical setting, as the ICF approach is an interaction between the health condition and contextual factors, and to plan holistic management. The advantage for physiotherapist to assess patients using the ICF approach is that it provides the physiotherapists with a conceptual framework which guides their questioning of a patient, assists them in organising the information gained from both subjective and objective assessments, and prompts them to integrate the information into the various components of the ICF. In this way, clinical reasoning is enhanced to provide a full and complete picture of the patient in his/her own context. This approach is also useful in generating outcome-based assessments which focus the physiotherapist’s treatment interventions on improving function.