ICIDH Research Articles

The ICIDH-2 – using the classification for statistics and research

The World Heath Organisation is in the process of revising the International Classification of Impairments, Disabilities and Handicaps (ICIDH). This paper describes the background to the ICIDH and the new features of the revised classification in relation to its aims and applications. The ICIDH has been extensively used in prevalence studies of disability and to measure the effectiveness of rehabilitation and examples of some of these studies are cited. The paper concludes with the plans for the future development of the ICIDH and the particular problems in translating the underlying concepts into assessment instruments that can provide valid and reliable data for research and statistical purposes including comparative studies.

Activities and functional assessment 1 year after spinal fusion for paralytic scoliosis.

The results of spinal fusion in patients with paralytic deformities are usually presented as the correction of the deformity. When evaluating the surgical results in such patients, it is advantageous to classify the patients into subgroups because of the varying dysfunction and disabilities. The aim of this study was to evaluate the effect of spinal fusion in patients with paralytic scoliosis in relation to function in terms of Impairments, activities in terms of Disabilities, and dependence in terms of Handicaps 1 year postoperatively, with emphasis on subgroups. A total of 94 patients with paralytic scoliosis and 18 different diagnoses were evaluated 1 year after surgery. The patients were classified according to whether or not they could understand verbal instructions. The patients were also grouped according to the Scoliosis Research Society classification of diagnoses. A set of instruments was used with the variables classified according to WHO's International Classification of Impairments, Disabilities, and Handicaps (ICIDH). This consists of the patient's/relative's motives for surgery, persistent skin discoloration, ambulating or use of wheelchair, use of a brace, sitting balance, weight distribution on a sitting surface, angle of scoliosis, reaching, pain estimation, activities of daily living (ADL) Klein and Bell, care given, time spent resting, and seating supports. The set of instrument also included a follow-up questionnaire comprising 12 different areas, where the patients/relatives assessed the results of surgery. The study showed that spinal fusion in paralytic scoliosis led to showed improvements in the whole group of patients at the Impairment level in the angle of scoliosis, sitting balance, weight distribution, and reduced number of patients with persistent skin discoloration, and at the Handicap level in reduced time for resting during the day, reduced number of seating supports in the wheelchair, and in the use of a brace. Most of the parameters were unchanged. The results in the subgroups were almost the same as in the whole group, although pain and reaching at the Impairment level, and ADL at the Disability level, could not be measured in the patients who were unable to understand verbal instructions. The subjectively assessed results showed that seating posture was ranked positively irrespective of the motive for surgery. The study showed that the patients with paralytic scoliosis maintained or improved their function and level of independence in terms of Impairment and Handicap 1 year postoperatively. The subjective results assessed by the patients/relatives also showed a positive outcome of surgery. Weight distribution on a seating surface was improved, but still uneven, and with respect to better sitting balance and increasing time sitting in a wheelchair, this can involve a risk for pressure sores and needs further investigation. When introducing outcomes including the Disability level, one must take the importance of homogeneity in the groups into consideration.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research.

The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of re evant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made. Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH. Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived hea th as the subjective part of the person level and domain-specific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal mode is intended to serve as a framework in which different outcomes can be positioned in relation to each other. Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

Quality of life and the ICIDH: towards an integrated conceptual model for rehabilitation outcomes research

Objective: The development of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) has led to the assessment of a wider range of relevant rehabilitation outcomes, but a need for a further broadening exists. In this article, a new proposal for an extended ICIDH is made. Method: Review of the literature on quality of life and of attempts to integrate the World Health Organization (WHO) biopsychosocial model and the ICIDH. Results: Our review shows three operationalizations of the concept of quality of life: as health, as well-being and, preferably, as a superordinate construct. None of the attempts to integrate the WHO biopsychosocial model have been entirely successful. Our new proposal is characterized by (a) incorporation of the organ, person and social levels of the ICIDH, (b) distinction between objective and subjective aspects of quality of life as a second axis in the model, resulting in somatic sensations as the subjective part of the organ level, perceived health as the subjective part of the person level and domain- specific life satisfaction as the subjective part of the social level, and (c) separation of the concept of general well-being or happiness as being distinct from the ICIDH. The proposal model is intended to serve as a framework in which different outcomes can be positioned in relation to each other. Conclusion: Our model is intuitively appealing and remains close to familiar concepts and models. However, it is as yet far from perfect, and we hope to provoke discussion to help further refinement.

The rehabilitation process for the geriatric stroke patient-an exploratory study of goal setting and interventions

Purpose: The aim was to describe and analyse the rehabilitation process of the geriatric stroke patient from two perspectives; the treatment goals expressed by the staff and the patient and the treatment interventions chosen by the physiotherapist and occupational therapist. A secondary aim was to test whether the process, treatment goals and interventions could be classified according to the International Classification of Impairments, Disabilities and Handicaps (ICIDH). Method: Qualitative interviews were performed with patients and personnel; diaries were used to register treatment interventions. The 30 interviews were categorized according to the goals expressed by physiotherapists, occupational therapists, physicians and patients. The diaries (n= 22) were analysed to describe how treatment interventions were connected in time, at what levels (impairment, disability and handicap) the interventions were directed, and finally, whether certain decisions were made in order to change the rehabilitation process. Results: The patients talked more about attaining their prestroke status than about their goals. The therapists set goals according to functional level, whereas the doctors expressed themselves in general terms. Three patterns of rehabilitation processes were found: one with clearly identified decision points, one with a set programme which was not changed through the process, and one where the goal was changed according to changes in medical status. Conclusions: The patient does not participate in the goalsetting process, and the vaguely expressed goals are not measurable. The rehabilitation process and reason for discharge demonstrate different patterns. Treatment interventions, if related to the ICIDH, give a clear picture of the process, though certain interventions do not fit in the classification.

The ICIDH and the Need for its Revision

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) published and used by the World Health Organization is currently undergoing a revision. Its conceptual basis is the medical model which leads to the medicalization of disability. From this point it is a short step to eugenics and a class-based evaluation of people with disabilities using the concept of 'normal'. People with disabilities are found to be lacking and a burden. The language and the logic of the ICIDH are faulty. It is replete with biased, handicapist language. In its present form and even in its proposed revised form (ICIDH-2) it is a threat to the disability community world wide.

Preoperative evaluation of activity and function in patients with paralytic scoliosis.

Preoperative evaluation of patients with paralytic scoliosis should take into account the consequences of surgery on the every day life of the patient. However, the parameters that are customarily used in these operations relate only to very narrow measures such as the angle of scoliosis or kyphosis. The aim of this study was to introduce a set of instruments appropriate for measuring both function and activities in paralytic scoliosis patients. The study took as its starting point the WHO International Classification of Impairments, Disabilities and Handicaps (ICIDH), in which an activity is described at the level of the individual and function at the level of the organ. A consecutive series of 100 paralytic scoliosis patients with 18 different diagnoses were evaluated preoperatively with a set of instruments that had been specially developed at Linköping hospital, in which the variables are classified according to the system used in the ICIDH. The set of instruments included general information and evaluation of activities and function--sitting, balance, weight distribution to sitting surface, angle of scoliosis, reaching, pain estimation, activities of daily living (ADL) Barthel and ADL Klein and Bell, care given, time spent resting, and seating supports). The results showed that patients with paralytic scoliosis constitute a heterogeneous group in activities and function. Even when the patients were grouped into four subgroups according to the Scoliosis Research Society Classification, they remained very heterogeneous. However, reaching, Klein and Bell Activities of Daily Living and pain could only evaluate patients who could understand verbal instructions. In those who could not, assessment relied more heavily on measures of function and level of dependence. It was concluded that the choice of assessment must be guided by the patient's ability to understand verbal instructions irrespective of his/her disorder. It is important to use the three levels--impairments, disabilities and handicaps-- in order to focus on the different outcomes in the two groups with respect to the patient's total situation.

The classification and measurement of disablement, with emphasis on depression, and its applications for clinical gerontology

This review describes the concept of disablement, with particular reference to the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps (ICIDH), and its forthcoming revision. Applications for a disablement classification are discussed, and the various approaches which have been applied to the measurement of disablement are reviewed. The relevance of disablement to psychiatric research and clinical practice is also addressed. In the second section of the review, data are presented from the last two phases of the Gospel Oak Survey, illustrating the value of simple measures of disablement in a community epidemiological study of the aetiology of late-life depression.

Social disadvantage in the international classification of impairments, disabilities, and handicap

The revision process of the international classification of impairments, disabilities and handicaps (ICIDH) is now in progress. Major changes are being considered which question one of the main fields, that of handicap, or social disadvantage. The scope of these changes goes beyond simple technical adjustments. It reaches the level where fundamental positions are adopted regarding the mainspring of public health policies. The purpose of this article is to review and discuss the main criticisms that have appeared in the literature about the dimension of handicap, including a study of the consequences that may result from keeping this dimension or from leaving it out. We suggest that the definition of handicap as a disadvantage has been overlooked, so that discussion has mainly taken place about the environment. Our opinion is that each criticism is based upon the emphasis given to a choice of strategy for preventing or reducing disablement. For some experts, the emphasis is on health care. For others, it is on social change. We share this interest in strategy. This is why we suggest that the conceptual framework is meant only for description, that it does not and should not include choices of strategy. We argue that it is the best way to promote appropriate description and therefore appropriate choice of strategies. Finally, we state that social disadvantage is a major dimension of the consequences of disorders and related problems, and should therefore remain in the framework, in order to provide appropriate information for better choices in strategy.

Describing the consequences of disorders: stuttering and the International Classification of Impairments, Disabilities, and Handicaps.

The International Classification of Impairments, Disabilities, and Handicaps (ICIDH) proposed by the World Health Organization (WHO, 1980) can be a useful method for describing the experiences of individuals exhibiting speech and language disorders such as stuttering. Unfortunately, the definitions for the terms impairment, disability, and handicap that were previously presented in the stuttering literature have not accurately represented the true purpose of the ICIDH as a tool for describing the consequences of disorders. This paper reviews the history of these terms in the stuttering literature and proposes alternate definitions that are more consistent with the use of the ICIDH elsewhere in the field of communication disorders, as well as within the health-related professions in general. Based on the ICIDH framework, a model is proposed for discussing the outcomes of various types of stuttering treatments in the context of an individual's experience of the stuttering disorder, and the implications for treatment outcomes research using this framework are discussed.

Functional outcome assessment of adults with traumatic brain injury.

The treatment of cognitive communicative impairments that occur due to traumatic brain injury is a relatively new field. There is a need for more empirical evidence supporting the efficacy of cognitive rehabilitation. Fortunately, the number of studies in this area have continued to grow over the past few years. The purpose of this article is to provide current information regarding the assessment of functional outcomes after traumatic brain injury using the theoretical framework of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which was developed by the World Health Organization (WHO).

Review on Interdisciplinary Rehabilitation of Visually Impaired and Blind People

Developments.During the last decades, several developments have led to a change in care and assistance for blind and visually impaired people. Due to insight into the complexity of visual problems, there has been a development in the disciplines that become involved in rehabilitation. Another development is the increase in types of assessment and rehabilitation methods and increased technical possibilities. In addition, the range of visual problems has become larger. Originally restricted to ocular-caused types of visual impairments, now also visual problems caused by cerebral problems (or a mixture of the two types) have come into focus. These developments have led to a need for coordination and cooperation with respect to administration (planning appointments, keeping track of who was doing what with the client) and also with respect to content of the work, namely, treatment has become interdisciplinary. Interdisciplinary Rehabilitation.Need for a conceptual framework by the several disciplines led to the development of an interdisciplinary model. This model consists of three elements: (a) the main principles of interdisciplinary teamwork, (b) a scheme of the rehabilitation process, and (c) use of the International Classification of Impairments, Disabilities and Handicaps (ICIDH) as the common conceptual framework. From the perspective of visual rehabilitation, adaptations were neccessary, mainly in the classifications of ocular and visual impairments, the classification of other sensory impairments, and in classifications of disabilities. “Handicap” became regarded as the consequence in terms of changes in the fulfillment of social roles. With the elaborations mentioned, it is possible to apply the ICIDH concepts in rehabilitation for visually impaired and blind people. During the whole path of rehabilitation, practitioners must take into account the three dimensions of impairment, disability, and handicap, including the eye disease or disorder. Interdisciplinary Teamwork in Practice.At several regional rehabilitation centers in The Netherlands (part of the foundation Visio), it appears that the model, and especially the concepts, of the ICIDH is a major tool in specifying and integrating the diagnostic findings of different disciplines in a “visual profile.” It has also become the basis for further development in assessment instruments. Implementation of the interdisciplinary model has meant a clearer understanding of each professional's own viewpoint (and limitations) regarding clients' visual problems and request for help. As a result, compared to prior rehabilitation processes, a more structured and better qualitative way (interdisciplinarily) in which providers help clients during the rehabilitation process has emerged. Still in the near-future it will be necessary to evaluate the interdisciplinary process in a quantitative way. It is our hope that with this theoretical basis, it will become possible to evaluate the quality and effect of offered rehabilitation to our clients. It is our expectation that this model and, especially, the concepts of the ICIDH can contribute to further development and exchange of knowledge in the field of visual rehabilitation, both nationality and internationally.

Disablement outcomes in geriatric rehabilitation.

Until recently, knowledge in the field of geriatric rehabilitation has been based largely on empirical findings. There is a need for greater conceptual clarity about major disablement outcomes to provide a foundation for future theoretical research. Disablement terms promulgated by the World Health Organization's (WHO) International Classification of Impairments Disabilities and Handicaps (ICIDH) are reviewed and compared with those of an alternative model proposed by Saad Nagi in 1965. Distinctions are drawn between the disablement concepts each system includes to refer to (1) inherent attributes of patients and (2) the interaction of the patient with the social and physical environment. The importance of a disablement model reflecting this distinction between inherent and relational concepts is emphasized. Areas for fertile research opportunities in which the disablement concepts could be used are discussed. It is suggested that improved understanding of disablement outcomes could be most readily achieved by application of an epidemiologic model separating the factors affecting outcomes into three sets of variables: the host factors representing intra-individual attributes; the agent factors, which are the external event or events causing the disability; and the environmental factors, which relate to the physical or social surroundings in which the disability occurs. In future research efforts, a more theoretical approach to studying disablement outcomes is advocated as a basis for improvements in geriatric rehabilitation.

Handicaps Associated with Epilepsy

The prevalence and severity of handicaps in 217 children and adolescents with epilepsy were assessed at the University of Goteborg, Ostra Hospital, Sweden, using the World Health Organization International Classification of Impairments, Disabilities and Handicaps (ICIDH).

Disability models in geriatrics: Comprehensive rather than competing models should be promoted

The usefulness of different models of disability is discussed. There is no clear-cut demarcation between ability and disability, and a person's functional abilities are highly dependent on societal as well as individual factors. One should not, however, promote models of disability that cover only the social aspects, but rather try to build comprehensive models including medical, psychological and social aspects of disability. The World Health Organization's International Classification of Impairments, Disabilities and Handicaps (ICIDH) provides a useful basis for such model building. The main weakness of the ICIDH is that it fails to take the subjective perceptions of the individual fully into account. Accordingly, it should be supplemented by some model of subjective well-being. Possible relationships between subjective well-being and the ICIDH concepts are discussed.

Post-stroke patients in rehabilitation. The relationship between biological impairment (CT scanning), physical disability and clinical depression

A study of 128 consecutive patients with thromboembolic stroke in a rehabilitation hospital from July 1988 to September 1990 found a prevalence of major depression of 17%. The patient population was described according to the principles of the World Health Organization's (WHO) International Classification of Impairments, Disabilities and Handicaps (ICIDH) according to biological impairment, measured by computerized tomography (CT) scanning of the brain and side of hemiparesis and physical disability, measured by functional movement and activities of daily living. Handicap, referring to the interaction between disability and the environmental situation, often defined as the subjective disadvantage of being ill, was not measured in this study. A stroke index with four items was generated from the parameters describing biological impairment and physical disability. The psychiatric rating scales (the 17-item Hamilton Scale for Depression (HAM-D), the Melancholia Scale [MES]and the Newcastle Diagnostic Depression Scale), and the new stroke-index showed adequate coefficients of Cronbach's alpha and Loevinger, suggesting that these scales have both adequate item correlation and homogeneity (adequate hierarchical structure). The impairment disability index of stroke thus seems to be a meaningful measurement of the specific factors of this disease. There was no correlation between the stroke-index and the psychiatric rating scales measuring the emotional dimension of disability caused by the disease expressed as depression. The results suggest that the depression found among stroke patients is not a simple reaction to the physical disability of the stroke.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S): a tool for the assessment of difficulties in selected areas of functioning of patients with mental disorders.

The World Health Organization Short Disability Assessment Schedule (WHO DAS-S) is an instrument for clinicians' assessment and rating of difficulties in maintaining personal care, in performing occupational tasks and in functioning in relation to the family and the broader social context due to mental disorders. The WHO DAS-S was developed and underwent preliminarily testing in the context of two international field trials of the multiaxial presentation of ICD-10 for use in adult psychiatry. The instrument was found to be useful, user-friendly and reasonably reliable for use by clinicians belonging to different schools of psychiatry and psychiatric traditions. Further work on the WHO DAS-S should include development of national adaptations of the instrument, studies of concurrent validity of the instrument and modification of the instrument to accommodate changes in the next edition of the International Classification of Impairments, Disabilities and Handicaps (ICIDH).

Functional outcome of lower-limb amputees: a prospective descriptive study in a general hospital.

This paper describes functional outcome of a population of lower limb amputees five months after amputation compared with their preoperative functional abilities and studies the relationship between potential determinants and functional outcome. Twenty out of 26 patients who underwent a lower limb amputation between December 1993 and August 1994 in a general hospital in Amsterdam were included in the study. Their functional abilities before amputation were retrospectively assessed using an ICIDH (International Classification of Impairments, Disabilities and Handicaps)-based questionnaire. Functional outcome was assessed after amputation of the lower limb using ICIDH-based and SIP (Sickness Impact Profile)-questionnaires. The mean SIP scores were high (referring to a low functional outcome). Disabilities were spread over the five disability fields of the ICIDH. The functional outcome of the diabetic versus the non-diabetic group was lower on the physical, activities of daily living (ADL), psychological and communicative categories of the ICIDH. In most patients, functional outcome decreased. The diabetic patients compared to the non-diabetics showed more diversity in functional outcome, compared with their preoperative functional abilities. Increasing age is significantly associated with a low functional outcome on the SIP scores. Diabetes is age-related for this sample. Co-morbidity and motivation are strongly age-related for this sample. It was concluded that lower-limb amputees appear quite disabled in all disability categories of the ICIDH and as assessed by the SIP scores. In most patients, functional abilities decrease after lower limb amputation. Age seems to be a significant factor related to functional outcome.

Occupational therapy in hospital based care in the Netherlands: a comparison of occupational therapy in general care (nursing homes, rehabilitation centres and general hospitals) and psychiatric care

AbstractObjective: to investigate (1) whether differences in occupational therapy practice exist between general and psychiatric care and (2) whether differences in occupational therapy practice exist between general care settings. The four most common settings where occupational therapists work in the Netherlands (nursing homes, rehabilitation centres, general hospitals and psychiatric hospitals) were studied.Method: a total of 143 therapists, working in 49 occupational therapy departments, participated in this study. They collected data on 1051 patients. For each patient a standard registration form, based on the International Classification of Impairments Disabilities and Handicaps (ICIDH) was filled out. This form contained information about (i) patient characteristics (ii) occupational therapy diagnosis and treatment goals in terms of ICIDH and (iii) treatment characteristics.Results and conclusions: occupational therapy treatment goals and interventions showed clear differences between psychiatric and general care settings. The differences in occupational therapy practice across general care settings were small. Copyright © 1996 Whurr Publishers Ltd.

The International Classification of Impairments, Disabilities and Handicaps (ICIDH)--results and problems.

In 1980, the World Health Organization (WHO) published the International Classification of Impairments, Disabilities and Handicaps (ICIDH). Although these three concepts of impairment, of disability, and especially of handicap have been criticized for many reasons, the ICIDH has given rise to extensive research and other activities world-wide, resulting in more than a thousand publications. The ICIDH has been translated into numerous languages. The classification itself, developed for trial purposes, shows the large variety for the items of each basic term. Practical experience, however, has shown that the ICIDH cannot be applied without problems. This is especially true for the handicap concept.