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Editor's Notes |
As physical therapists, our ability to communicate is fundamental to both the practice and the science of our profession. Conceptual frameworks, such as the disablement model, can provide a rudimentary language, guiding not only the way we generate our terminology but the way we generate our measurements and our hypotheses. Before something can be measured and studied, it must be defined; and to be clinically and scientifically useful, the definition must have universality—that is, the ability to be understood and used by similarly trained people—as well as have a basis in sound theoretical assumptions.1
Within physical therapy, the disablement model has proven useful in describing the consequences of disease and injury both at the level of the person and at the level of society.2 The term disablement—as adapted from Nagi's seminal work3—refers to the "various impact(s) of chronic and acute conditions on the functioning of specific body systems, on basic human performance, and on people's functioning in necessary, usual, expected, and personally desired roles in society."4 In APTA's Guide to Physical Therapist Practice (Guide),5 an expanded version of the disablement model serves as the conceptual basis for the elements of patient/client management. The core disablement concepts—impairments, functional limitations, and disabilities—have become generally accepted and constitute a language widely used by physical therapists and within the pages of Physical Therapy. In my view, the disablement model has increased physical therapists' ability to be understood not only by each other but across related professional disciplines. Disablement language as used outside physical therapy is changing, however.
The World Health Organization (WHO) has developed a "family" of internationally accepted classifications with the intent of providing a framework to classify and code information about health and to equip the international community with a standardized language that would facilitate communication about health across the globe and across various disciplines. The most widely known WHO classification is the International Statistical Classification of Diseases and Related Health Problems,6 now in its 10th revision (ICD-10). The ICD-10 enables the collection of diagnostic information for clinical and epidemiological purposes and the compilation of national mortality and morbidity statistics by WHO member states.
The newest WHO classification is the International Classification of Functioning, Disability and Health (ICF),7 a major revision of its earlier formulation, the International Classification of Impairments, Disabilities, and Handicaps (ICIDH).8 The ICF framework—which is similar to the disablement model articulated in the Guide—synthesizes the concepts used in previous disablement models and describes the etiology of functioning and health not only in association with underlying health conditions but also in association with personal and environmental factors. The ICF introduces new disablement language to replace older terminology that implied distinctions between individuals or populations that are healthy and individuals or populations that have disabilities.
In this new language of disablement, the ICF expresses each disablement component in positive and negative terms. It defines body functions and structures as physiological functions of body systems or anatomical elements, such as organs, limbs, and their components, with impairments defined as problems in body function or structure such as significant deviation or loss. Activity is defined as the execution of specific tasks or actions by an individual, with activity limitations considered to be difficulties that an individual might have in executing activities. Participation is conceptualized as encompassing involvement in a life situation, with participation restrictions considered to be problems that an individual might experience in real-life situations.7 A person who has had a stroke, for example, might have hemiparesis of the right upper and lower extremities (an impairment), have difficulty walking (an activity limitation), and be unable to continue working (a participation restriction).
The ICF framework takes a broad biopsychosocial view of health that is familiar to physical therapists. It's exciting because it provides international endorsement of a disablement framework that looks beyond mortality and disease to focus on how people live with their conditions. The ICF language, if widely adopted, will promote an international language that has the potential to facilitate communication and scholarly discourse across professions and national boundaries, stimulate interdisciplinary research, and ultimately better inform health policy and management.9 Following approval of the ICF by the World Health Assembly in 2001, all WHO member states were asked to implement the ICF in their respective health sectors. Responsible for disseminating the use of the ICF in the United States, the National Center for Health Statistics (NCHS) houses the WHO Coordinating Center for the Family of International Classifications for North America.
Did the physical therapy profession need a new disablement language? In my opinion, no. The disablement concepts and terminology introduced by Nagi were clear and were defined in ways that are similar to the concepts and definitions in the new ICF. Nonetheless, the international community has acted, and I applaud the WHO and those who developed the ICF for promoting the worldwide adoption of the disablement framework and a common and consistent language.
At a time when the contributions being made by physical therapist scientists are widely represented and recognized throughout the health care professions and the broader scientific community, we need to be cognizant of the changing language of disablement and to consider using the ICF framework in our scholarly discourse and research. To do otherwise runs the risk of isolating physical therapy from other disciplines—and isolating ourselves from rehabilitation researchers, clinicians, and scholars across the globe.
References
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