ICF AND STROKE
MKF IN MOŽGANSKA KAP
mag. Pavel Ptyushkin, dr. med.
Inštitut Republike Slovenije za rehabilitacijo, Ljubljana
Abstract
In spite of a large number of existing scales for stroke outcome assessment, the problem of precise, holistic and unified international scale for use by clinicians, researchers and policy-makers is still under discussion. International Classification of Functioning (ICF) is a tool elaborated by the World Health Organisation in order to provide a multi-dimensional framework for health and disability. ICF aims to provide a conceptual basis and an universal common language for describing and understanding patient's health status, reaching beyond mortality, diseases and medical diagnoses. Some studies have shown that ICF is efficient for assessing stroke outcomes and may represent an interesting alternative to be used for reaching better outcomes in the rehabilitation process, as well as for research and policy-making purpuses.
Key words:
ICF, stroke rehabilitation, disability
Izvleček
Čeprav obstaja veliko lestvic za ocenjevanje izida po možganski kapi, ostaja problem natančne, celostne in poenotene mednarodne lestvice za potrebe kliničnega dela, raziskovanja in javnozdravstvenega odločanja odprt. Mednarodna klasifikacija funkcioniranja, zmanjašane zmožnosti in zdravja (MKF, angl. skrajšano ICF) je orodje, ki ga je razvila Svetovna zdravstvena organizacija kot večrazsežen okvir pojmovanja zdravja in zmanjšane zmožnosti. MKF nudi pojmovne temelje in univerzalen skupni jezik za razumevanje in opis bolnikovega zdravstvenega stanja in presega razvrstitve po umrljivosti, boleznih in po medicinskih diagnozah. Nekaj študij je pokazalo, da je MKF učinkovita za ocenjevanje izida po možganski kapi in je lahko zanimiva alternativa v prizadevanjih za izboljšanje izida rehabilitacije, kakor tudi za uporabo pri raziskovalnem delu in odločanju v okviru zdravstvene politike.
Ključne besede:
MKF, rehabilitacija po možganski kapi, zmanjšana zmožnost
INTRODUCTION
Stroke is a major health problem that is among the most common causes of death and disability, especially in industrialized societies. Many people who have survived stroke are facing its long-term consequences, which are usually complex and heterogeneous and may result in problems across multiple domains of functioning (1). Lack of a compherensive, standard and universal international tool for the evaluation and measurement of stroke outcomes has been a major difficulty for practitioners, researchers and policy makers. The use of the International Classification of Functioning, Disability and Health (ICF) as such a tool is currently under active debate.
ASSESSMENT OF STROKE OUTCOMES -AN OVERVIEW
Following stroke, health status measures may be used for the examination and description of stroke impact, for monitoring, intervention evaluation, quality management, surveys,
for individual as well as macro-level health-care planning and decision making. Most frequently, the effects of stroke are assessed by methods such as health professional ratings and performance tests. However, stroke survivors' everyday lives are affected in a variety of ways not easily captured by this type of method. Some health-related quality of life measures provide additional patient-centered approach to specify consequences of stroke (2). According to the US Agency for Health Care Policy and Research, there are more than 30 scales used for different purpuses - e.g., prehospital assessment, acute phase scales, functional assessment, and outcome assessment - which makes any comparison even at the national level a very challenging task (3). Some of these scales are briefly described in Table 1.
In the recent years, there has been a growing awareness that stroke assessment should extend beyond the traditional outcome of mortality and neurological symptoms to include physical, psychological and social functioning. This approach is being increasingly applied in health care and research, especially in rehabilitation medicine (1). Several national and international guidelines on stroke management
have been published also containing recommendations on interventions and assessment strategies targeted towards the diverse areas of post-stroke disability to be considered beyond the acute phase of the disease. In one of the recent European recommendations concerning the organization of stroke care by the European Stroke Initiative (EUSI), the careful assessment of the degree of disability in post-stroke patients is regarded as most important. According to the EUSI recommendation, disability assessment should comprise the domains of motor weakness, sensory and proprioceptive deficits, intellectual impairment, and emotional distress and motivational disturbances. However, no recommendations on specific instruments to be used for the measurement of these areas are given (4). The general problem that arises from the use of the existing scales for stroke assessment, from which some are excellent and have demonstrated applicability and practical value, is the fragmentary approach when using some of them and difficulties are necessarily associated with compatibility between different tools. Another problem is the need of creation of a common language and a common information space for the national and international purpuses.
ICF AND STROKE PATIENTS ASSESSMENT
International Classification of Functioning, Disability and Health is a relatively new tool, developed by the WHO for assessment of the level of health of an individuum. It provides a multi-dimensional framework for health and disability suited to the evaluation of stroke outcome. ICF aims to provide a conceptual basis and a universal common language for understanding and describing patients health status, reaching beyond mortality, diseases and medical diagnoses. As it belongs to the family of international classifications, it provides a valuable tool to describe and compare the health of populations in an international context (5). The ICF has been already applied in physical therapy and rehabilitation, especially in the field of neurorehabiliotation, to facilitate multidisciplinary team communication, to structure the rehabilitation process, for goal setting and assessment, for documentation and for reporting (6).
According to the ICF framework outcomes may be measured at three levels: body functions/structures, activities and participation. Equal importance is given also to the environmental factors, which reflects the complex nature of disability for an individual. As rehabilitation can be defined as a reiterative problem solving and educational process that focuses on disability (altered activities) and aims to maximize participation in society while minimizing the stress on and distress of the patient and family (7), ICF philosophy and structure perfectly suits this approach to the rehabilitation process. Stroke patients experience poor functioning across the mentioned range of outcomes. Impairment in body function/structure includes mobility limitations, impaired mental status and depression. Stroke patients often
experience limitations in activities, ranging from dependance in performing basic activities of daily living (ADL) to difficulties in completing social interactions. Furthermore, stroke patients report restricted participation across various life domains. For example, patients experience low levels of health related quality of life (HRQOL) (8).
Several studies have shown the compatibility and applicability of ICF in stroke rehabilitation process. Schepers et al. outline that functional outcome measures and the ICF are concurrently applied in stroke rehabilitation medicine. This simultaneous use necessitates a further understanding of their relationship and compatibility. Using ICF, it is possible to identify and compare the concepts contained in different outcome measures. According to Geyh et al., most of such concepts could be linked to the ICF (9).
Barak and Duncan draw attention to the increased need of the selection of the appropriate outcome measures in stroke and outline that clinical relevance in stroke outcome measures can be optimized by incorporating a framework of health and disability such as ICF (10).
Mayo et al. studied the possible benefits from incorporation of the ICF into an electronic health record to create indicators of function. The study was performed on post-stroke patients and proved that the ICF coding provides enhanced information about specific functional limitations experienced by persons with stroke. This information may assist with provision of services for persons with stroke and help to explain health discrepancies (11).
At the same time, Morielo et al. explored the possibility of using the ICF for creating coded functional status indicators specific for stroke from the stroke impact scale - 16 (SIS-16) and concluded that ICF can capture most items from functional status measures, such as SIS-16. They also stressed that these items can be mapped onto a standard coding framework, illustrating the potential for increased use of ICF (and ICF core sets) in electronic health records and other computerized health information systems (12).
ICF CORE SET FOR STROKE
According to Stucki and associates, the new language of ICF is an exciting landmark event for rehabilitation. However, in their opinion the success of ICF will depend on its compatibility with measures used in rehabilitation and on the improvement of its practicability (13). The use of the original full version of ICF in daily practice was debated because of its complexity and length. This lead to the understanding of the need for identification of relevant ICF categories in patients with some frequent chronic health conditions, including stroke. For practical purpuses and in line with the concept of condition-specific health-status measures, it was considered to link specific conditions or diseases
Table 1: Stroke assessment scales according to the US Agency for Health Care Policy and Research (3).
Type	Name and Source	Time	Strengths	Weaknesses
Global Assessment Scales				
Global disability scale	Rankin Scale	5 min.	Good for overall assessment of disability.	Walking is the only explicit assessment criterion. Low sensitivity.
Measures of disability	Functional Independence Measure [FIM]	40 min.	Widely used for stroke. Measures mobility, ADL, cognition, functional communication.	"Ceiling" and "floor" effects.
Activities [of Daily Living) Assessment				
Activities of daily living [ADL]	Barthel Index	5-10 min.	Widely used for stroke. Excellent validity and reliability.	Low sensitivity for high-level functioning.
Measures of instrumental	PGC Instrumental Activities of Daily Living	5-10 min.	Measures broad base of information necessary for independent living.	Has not been tested in stroke patients.
ADL	Frenchay Activities Index	10-15 min.	Developed specifically for stroke patients; assesses broad array of activities.	Sensitivity and interobserver reliability not tested; sensitivity probably limited.
Specific Scales for Mental Status and Speech Functions Assessment				
Mental status screening	Folstein Mini-Mental State Examination	10 min.	Widely used for screening.	Several functions with summed score. May mi-sclassify patients with aphasia.
	Neurobehavioral Cognition Status Exam (NCSE)	10 min.	Predicts gain in Barthel Index scores. Unrelated to age.	Does not distinguish right from left hemisphere. No reliability studies in stroke. No studies of factorial structure. Correlates with education.
Depression scales	Beck Depression Inventory (BDI) (BDI)	10 min	Widely used, easily administered. Norms available. Good with somatic symptoms.	Less useful in elderly and in patients with aphasia or neglect.High rate of false positives. Somatic items may not be due to depression.
	Center for Epidemiologic Studies Depression (CES-D)	< 15 min.	Brief, easily administered, useful in elderly, effective for screening in stroke population.	Not appropriate for aphasic patients.
	Geriatric Depression Scale (GDS)	10 min.	Brief, easy to use with elderly, cognitively impaired, and those with visual or physical problems or low motivation.	High false negative rates in minor depression.
	Hamilton Depression Scale	< 30 min	Observer rated; frequently used in stroke patients.	Multiple differing versions compromise interobserver reliability.
Assessment of speech	Boston Diagnostic Aphasia Examination	1-4 hours	Widely used, comprehensive, good standardization data, sound theoretical rationale.	Time to administer long; half of patients cannot be classified.
and language functions	Porch Index of Communicative Ability (PICA)	1/2-2 hours	Widely used, comprehensive, careful test development and standardization.	Time to administer long. Special training required to administer. Inadequate sampling of language other than one word and single sentences.
	Western aphasia Battery	1-4 hours	Widely used, comprehensive.	Time to administer long. "Aphasia quotients" and "taxonomy" of aphasia not well validated.
Specific Scales for Motor Functions and Mobility Assessment				
Assessment of motor function	Fugl-Meyer	30-40 min.	Extensively evaluated measure. Good validity and reliability for assessing sensorimotor function and balance.	Considered too complex and time-consuming by many.
	Motor Assessment Scale	15 min.	Good, brief assessment of movement and physical mobility.	Reliability assessed only in stable patients. Sensitivity not tested.
	Motricity Index	5 min.	Brief assessment of motor function of arm, leg, and trunk.	Sensitivity not tested.
Balance assessment	Berg Balance Assessment	10 min.	Simple, well established with stroke patients, sensitive to change.	None observed.
Mobility assessment	Rivermead Mobility Index	5 min.	Valid, brief, reliable test of physical mobility.	Sensitivity not tested.
Quality of Life and Family Assessment				
Family assessment	Family Assessment Device (FAD)	30 min.	Widely used in stroke. Computer scoring available. Excellent validity and reliability. Available in multiple languages.	Assessment subjective; sensitivity not tested; "ceiling" and "floor" effects.
Health status/ quality of life measures	Medical Outcomes Study (MOS) 36-Item Short-Form Health Survey	10-15 min.	Generic health status scale SF36 is improved version of SF20. Brief, can be self - administered or administered by phone or interview. Widely used in the United States.	Possible "floor" effect in seriously ill patients [especially for physical functioning], suggests it should be supplemented by an ADL scale in stroke patients.
	Sickness Impact Profile (SIP)	20-30 min.	Comprehensive and well-evaluated. Broad range of items reduces "floor" or "ceiling" effects.	Time to administer somewhat long. Evaluates behavior rather than subjective health; needs questions on well-being, happiness, and satisfaction.
to the correspondent relevant ICF categories of functioning (14). Although some authors (for example, McIntyre and Tempest) (15) question this premise and fear that the introduction of specific ICF core sets for specific conditions may push the classification away from the holistic approach back to a medical diseased-centred model, ICF core sets were elaborated for 12 health conditions, including stroke (16). It should also be noted that development of the core set
for stroke took place partly in response to disease-specific clinical guidelines, e.g., the Intercollegiate Stroke Working Party guidelines.
Two versions of ICF Core Set for stroke have been developed - a brief and a comprehensive one. Both of them are presented in Table 2 (17). In the initial development, it was felt that the disease-specific core sets would tend to
Table 2: ICF Core Set for Stroke (17). (ICF code and ICF 2nd level category title; categories in bold belong to the Brief ICF Core Set for Stroke.)
Categories of component b	Categories of component s	Categories of component d	Categories of component e
(Body Functions)	(Body Structures]	(Activities and Participation]	(Environmental Factors]
b110 Consciousness functions	s110 Structure of brain	d115 Listening	e110 Products or substances for personal
b114 Orientation functions	s410 Structure of cardiovascular system	d155 Acquiring skills	consumption
b117 Intellectual functions	s720 Structure of shoulder region	d160 Focusing attention	e115 Products and technology for personal use
b126 Temperament and personality functions	s730 Structure of upper extremity	d166 Reading	in daily living
b130 Energy and drive functions	s750 Structure of lower extremity	d170 Writing	e120 Products and technology for personal indoor
b134 Sleep functions		d172 Calculating	and outdoor mobility and transportation
b140 Attention functions		d175 Solving problems	e125 Products and technology for communication
b144 Memory functions		d210 Undertaking a single task	e135 Products and technology for employment
b152 Emotional functions		d220 Undertaking multiple tasks	e150 Design, construction and building products
b156 Perceptual functions		d230 Carrying out daily routine	and technology of buildings for public use
b164 Higher-level cognitive functions		d240 Handling stress and other psychological	e155 Design, construction and building products
b167 Mental functions of language		demands	and technology of buildings for private use
b172 Calculation functions		d310 Communicating with - receiving - spoken	e165 Assets
b176 Mental function of sequencing complex		messages	e210 Physical geography
movements		d315 Communicating with - receiving - nonverbal	e310 Immediate family
b180 Experience of self and time functions		messages	e315 Extended family
b210 Seeing functions		d325 Communicating with - receiving - written	e320 Friends
b215 Functions of structures adjoining the eye		messages	e325 Acquaintances, peers, colleagues,
b260 Proprioceptive function		d330 Speaking	neighbours and community members
b265 Touch function		d335 Producing nonverbal messages	e340 Personal care providers and personal
b270 Sensory functions related to temperature		d345 Writing messages	assistants
and other stimuli		d350 Conversation	e355 Health professionals
b280 Sensation of pain		d360 Using communication devices and techniques	e360 Health-related professionals
b310 Voice functions		d410 Changing basic body position	e410 Individual attitudes of immediate family
b320 Articulation functions		d415 Maintaining a body position	members
b330 Fluency and rhythm of speech functions		d420 Transferring oneself	e420 Individual attitudes of friends
b410 Heart functions		d430 Lifting and carrying objects	e425 Individual attitudes of acquaintances, peers,
b415 Blood vessel functions		d440 Fine hand use	colleagues, neighbours and community
b420 Blood pressure functions		d445 Hand and arm use	members
b455 Exercise tolerance functions		d450 Walking	e440 Individual attitudes of personal care
b510 Ingestion functions		d455 Moving around	providers and personal assistants
b525 Defecation functions		d460 Moving around in different locations	e450 Individual attitudes of health professionals
b620 Urination functions		d465 Moving around using equipment	e455 Individual attitudes of health-related
b640 Sexual functions		d470 Using transportation	professionals
b710 Mobility of joint functions		d475 Driving	e460 Societal attitudes
b715 Stability of joint functions		d510 Washing oneself	e515 Architecture and construction services,
b730 Muscle power functions		d520 Caring for body parts	systems and policies
b735 Muscle tone functions		d530 Toileting	e525 Housing services, systems and policies
b740 Muscle endurance functions		d540 Dressing	e535 Communication services, systems and
b750 Motor reflex functions		d550 Eating	policies
b755 Involuntary movement reaction functions		d570 Looking after one's health	e540 Transportation services, systems and
b760 Control of voluntary movement functions		d620 Acquisition of goods and services	policies
b770 Gait pattern functions		d630 Preparing meals	e550 Legal services, systems and policies
		d640 Doing housework	e555 Associations and organizational services,
		d710 Basic interpersonal interactions	systems and policies
		d750 Informal social relationships	e570 Social security services, systems and
		d760 Family relationships	policies
		d770 Intimate relationships	e575 General social support services, systems
		d845 Acquiring, keeping and terminating a job	and policies
		d850 Remunerative employment	e580 Health services, systems and policies
		d855 Non-remunerative employment	e590 Labour and employment services, systems
		d860 Basic economic transactions	and policies
		d870 Economic self-sufficiency	
		d910 Community life	
		d920 Recreation and leisure	
focus on domains within body functions and activity and participation. In reality, when the ICF disease-specific core sets were published, consensus agreement had identified that approximately one fifth of core set content belongs to environmental factors. For example, in the core sets for stroke, 25% of concepts listed are environmental factors. This suggests a strategic change in core set development that reflects the complex nature of disability for an individual (15).
ICF AND APHASIA
Simmons-Mackie and Kagan discussed the use of the ICF as organisational framework for approaching management of impairments and consequences of aphasia, which is also caused by stroke. The practical role of ICF in reaching the final goal of maximizing the quality of life of patients with aphasia was studied. They found out that the dinamic interaction of key ICF constructs on life quality facilitates move toward more effective outcomes for people affected by aphasia (18).
CHALLENGES AND BENEFITS OF THE ICF IMPLEMENTATION
The use of ICF within a multidisciplinary team has already been documented as beneficial for clarifying the team roles and facilitating clinical reasoning. Therefore, the introduction of the ICF core sets can further guide multidisciplinary teams and individual practitioners in service delivery. However, some authors have stated that ICF should only be used as an adjunct to rehabilitation terminology as it is unsufficient at present to be used in isolation. For example, Haglund and Henriksson are convinced that the classification can serve as a useful tool for occupational therapists and supports communication between professions, but is not sufficient as a professional language for occupational therapists (19).
There is still a discrepancy in evaluation of the introduction of the ICF as a new framework for assessment of stroke outcomes at the national and international level. But if we are willing to adhere to the ICF model, we thereby accept the challenge that the goal of rehabilitation is life role participation, with functional improvement as an important intermediary step. The ICF model suggests that we intervene at multiple lower levels (e.g., pathology and impairment) in order to improve the higher levels of function and life role participation. The ICF model also suggests that we should measure things at each level. Not only can we then better understand the response to treatment at each level, but we can also begin to understand relationships between levels. With the ICF model putting forward the challenge of restoring life role participation, it becomes important to design and test interventions that result in impairment gains sufficiently
robust to be reflected in functional activities and further in life role participation (20).
Hence, taking into consideration that measuring the outcome of health care is a "central component of determing therapeutic effectiveness and, therefore, the provision of evidence-based healthcare" (21) and that our understanding of the effectiveness of a given rehabilitation intervention is, in part, determined by our ability to measure the impact of that intervention on an individual's functional ability and health, (22) the posibility of using a common, comprehensible, multidimensional and internationally recognized tool that above all would allow professionals in different parts of the world speak the same professional language should not be underestimated.
CONCLUSIONS
A number of generic and specific tools for stroke assessment exist. Different scales and approaches are used in different ways for measuring stroke outcomes. Among them, ICF may represent one of the most integrative and comprehensive instruments in the future. The implementation of ICF would also be a step forward in creation of a common language for health professionals, researchers and policy makers who deal with stroke patients all over the world. However, presently, the problem of quantification and precise measurement of difficulties experienced by the patient using the generic scale is still not resolved and further research and testing in different clinical and rehabilitation contexts are needed to improve its use and make possible its application more wide.
ACKNOWLEDGEMENT
The author is grateful to his colleagues Prof. Helena Burger, MD, PhD, and Gaj Vidmar, PhD, for guidance and assistance in preparing the manuscript.
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