THERAPEUTIC RECREATION JOURNAL Vol. 41, No. 1, 61-81, 2007 The International Classification of Functioning, Disability, and Health: Therapeutic Recreation Code Sets and Salient Diagnostic Core Sets David Howard, Cari Browning, and Youngkhill Lee In 2001 the World Health Organization published their latest model for classifying health, human function, and disability. The International Classification of Functioning, Disability, and Health (ICF) is now gaining global acceptance and use in many sectors of government, health-care settings, social services, and health-related disciplines and organizations. In order to fully participate in the globalization of an increasing ICF-based health-related framework, the profession of therapeutic recreation needs to be aware and active in utilizing important concepts of the ICF within practice, research, and higher education. This article has two primary objectives. First, to identify and descdbe components of the ICF germane to therapeutic recreation/recreation therapy and functional outcomes. Second, to identify published literature Biographical Sketch: David Howard, Ph.D, MSW, CTRS is an Assistant Professor in the Department of Recreation and Sport Management at Indiana State University. He is a member of NTRS and ATRA, and former Chair of the Public Health-WHO Team for the American Therapeutic Recreation Association. Cari Browning, BA, CTRS is a graduate student at the University of Brighton (United Kingdom), is a member of the ATRA Public Health-WHO Team, and recently completed a field placement at the World Health Organization in Geneva, Switzerland. Youngkhill Lee, PhD, CTRS is an Associate Professor at Indiana University and is a member of the ATRA Public Health-WHO Team. The authors would like to recognize and thank Ray West, Dr. John Shank (Temple University), and Dr. Thomas Skalko (East Carolina University) for their time and effort in reviewing a preliminary draft of this manuscript. First Quarter 2007 61
The International Classification ofFunctioning, Disability, and Health:Therapeutic Recreation Code Sets andSalient Diagnostic Core Sets
David Howard, Cari Browning, and Youngkhill Lee
In 2001 the World Health Organization published their latest model for classifying health, humanfunction, and disability. The International Classification of Functioning, Disability, and Health(ICF) is now gaining global acceptance and use in many sectors of government, health-caresettings, social services, and health-related disciplines and organizations. In order to fullyparticipate in the globalization of an increasing ICF-based health-related framework, theprofession of therapeutic recreation needs to be aware and active in utilizing important conceptsof the ICF within practice, research, and higher education. This article has two primaryobjectives. First, to identify and descdbe components of the ICF germane to therapeuticrecreation/recreation therapy and functional outcomes. Second, to identify published literature
Biographical Sketch: David Howard, Ph.D, MSW, CTRS is an Assistant Professor in theDepartment of Recreation and Sport Management at Indiana State University. He is amember of NTRS and ATRA, and former Chair of the Public Health-WHO Team for theAmerican Therapeutic Recreation Association. Cari Browning, BA, CTRS is a graduatestudent at the University of Brighton (United Kingdom), is a member of the ATRA PublicHealth-WHO Team, and recently completed a field placement at the World HealthOrganization in Geneva, Switzerland. Youngkhill Lee, PhD, CTRS is an Associate Professorat Indiana University and is a member of the ATRA Public Health-WHO Team.
The authors would like to recognize and thank Ray West, Dr. John Shank (Temple University), and Dr.Thomas Skalko (East Carolina University) for their time and effort in reviewing a preliminary draft of thismanuscript.
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that links the ICF to disease and population-specific diagnoses that therapeutic recreationspecialists may find useful.
KEYWORDS: World Health Organization, ICF, therapeutic recreation, recreation therapy,code set, core set
The International Classification of Func-tioning, Disability, and Health (ICF) is thesecond and latest attempt by the World HealthOrganization (WHO) to provide a conceptual-ization of health and disability (WHO, 2001).The WHO'S first conceptualization was pub-lished in 1980 and was called the InternationalClassification of Impairments, Disabilities,and Handicaps or ICIDH (WHO, 1980). Thecurrent WHO Family of International Classi-fications includes the ICF and the often-usedInternational Statistical Classification of Dis-eases and Related Health Problems (ICD-10).The ICF is unique because it is a classificationof health and health-related domains that listsand descdbes body functions and structures,activities and participation and is expedencingacceptance and utilization throughout theworld.
A commonly used term, globalization re-fers to the development of a new global con-sciousness that is based on changing concep-tions of reality (Harris & Seid, 2004;Robertson, 1992). The WHO attempts to cre-ate that reality and infuse a new global con-sciousness as illustrated in the four pdmaryaims of the ICF. These are: a) to provide ascientific basis for understanding and studyinghealth and health outcomes, b) to establish acommon language for describing health in or-der to improve communication at all levels ofhealth and society, c) to permit comparison ofdata across countries, health care disciplines,and health-related services, and d) to provide asystemic coding scheme for health informationsystems. In addition to these aims, the WHOproposes five ways in which the ICF may beapplied in the future. These are as a: a) statis-tical tool for collecting and recording data, b)research tool to measure outcomes and qualityof life or environmental factors, c) clinical tool
dudng assessment or to assist matching treat-ments with a person health condition, d) socialpolicy tool when designing, as examples, so-cial security or compensation systems, and e)educational tool for design of curdculum or toraise awareness or undertake social action forthe betterment of society and its individuals(WHO, 2001).
Because an individual's health, level offunctioning, and/or disability status occurswithin the context of his or her whole life andthe environment in which he or she lives, theICF identifies environmental factors that po-tentially impact the person. This perspectivefits with the philosophy of therapeutic recre-ation services which tend to address the wholeperson and often utilizes a holistic approach.Complementary to this, the ICF is intended toaid efforts to maximize health as "a state ofcomplete physical, mental and social well-being and not merely the absence of disease orinfirtnity" (WHO, 1946). In the United Statesand Canada, the North America CollaboratingCenter on ICF has held meetings for more thana decade to discuss and educate practitioners,scholars, and policy makers on the use ofWHO classifications. Therapeutic recreation(TR) professionals have attended and partici-pated in these proceedings for the past fouryears (Greenberg, 2006; Howard, 2006; Mc-Cormick, Lee, & Jacobson, 2004).
The purpose of this article is to provide thereader with an understanding of the compo-nents of the ICF believed to be most germaneto therapeutic recreation (TR) professionals.This will be accomplished by: a) identifyingaspects of the ICF which are thought by theauthors to be the most salient to TR and b)identifying published literature that ties theICF to disease-specific and population-specificdiagnoses or conditions, and certain treatment
62 Therapeutic Recreation Journal
Healili cotidiiioii(disorder or disease)
Body Functions andStructures
Activities PariicipaiiDii
t tEnviroiiiuciital
FactorsPersonalFactors
Figure I. International Classification of Functioning, Disability and Health. From WorldHealth Organization (2001). International Classification of Functioning, Disability, and Health.Geneva, Switzerland: World Health Organization, p. 18.
settings. The information contained herein willhelp TR practitioners, researchers, policy-makers and educators to link this globally-accepted classification system to day-to-daypractice. This will occur, in part, by adoptingthe common language of the ICF when work-ing along side other health professionals whenaddressing the broad needs of people withdisabilities. Note: For maximum benefit, it isrecommended that the reader have a basicunderstanding of the ICF in order to betterutilize the information in this article. A basicunderstanding may be obtained by reading thearticle by Porter and Van Puymbroeck ([Inpress]) in this issue of the Therapeutic Recre-ation Journal, or by accessing the Beginner'sGuide found at the WHO's ICF website(http://www3.who.int/icf/icftemplate.cfm).
ICF Codes and the TR ProfessionConceptually, the ICF is a multi-compo-
nent model attempting to depict the holisticand interactive nature of an individual and his
or her health. As seen in Figure 1, the pdmarycomponents of the ICF are: a) body functionsand structures, b) activities and participation, andc) contextual factors found either within theperson and/or within his or her environment.
Because TR professionals work in so manyvaried community and clinically-based set-tings, the health-related problems of clients arediverse. According to the National Council forTherapeutic Recreation Certification (2005),35% of TR practitioners work in settings serv-ing people with psychiatric diagnoses, while30% work with older adults in places such asnursing homes or skilled living facilities.Eighteen percent of TRS work in physicalrehabilitation settings, 14% with clients whohave developmental disorders, and 3% in"other" settings. By age groupings, 38% of TRpractitioners work with older adults, 37% withadults, 12% with adolescents, 5% with pediat-dc populations, and 8% "other" where the TRrespondent indicated working with clients inmore than one age group.
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Because of this diversity in practice set-tings, the needs and problems of clients whomay potentially interact with a therapeutic rec-reation specialist (TRS) also vary greatly. TheTRS who works in health care settings pro-vides interventions that are decidedly treat-ment focused, odented to improving func-tional outcomes (referred to by many asrecreation therapy). However, TR has both theopportunity and responsibility to be aware ofsocial conditions and to be active in preventingillness, injury and disease. We also workwithin community and cultural environmentsto ensure that post-treatment lives are livedindependently and satisfactodly, with mini-mized impact of the initial disability or poten-tial secondary conditions. As the focus of ourdiscipline is on quality of life, and the holisticnature of recreation, leisure, sport, and free-time activity and its central role in quality oflife, the TRS often addresses physical, intel-lectual, emotional, social, cultural, sexual, andspiritual facets. Regardless of a TR profession-al's setting or scope of practice, the ICF hasrelevance and adds meaning and definition forpractice, research, and education.
The codes presented in this article as sa-lient to TR are not, however, meant to be anall-inclusive list of codes for TR, nor are theyendorsed by any one professional TR organi-zation. They are presented to aid the reader'sawareness of the scope of the ICF while gen-erating discussion and further efforts to en-hance the standing of TR as a profession witha place and purpose in today's world of healthcare and health promotion efforts. In creatingthis manuscdpt, it is the intent of the authors topresent information objectively and with ex-amples that illustrate balance of practice phi-losophies and recognition of the wide contin-uum of services a TRS may provide.
The three areas of the ICF most salient toTR are body functions, activities and partic-ipadon, and environmental factors. We willdiscuss each area to help the reader under-stand its relevance to TR practice, beginningwith how codes are constructed. Codes inthe ICF begin with a letter representing
different domains. Body functions beginwith a "b," body structures with an "s."Activity and participation codes always startwith a "d" and environmental codes beginwith an "e." Personal factors, given the num-ber and complexity of personal factors inpeople's lives, are not presently coded. Ineach case, the code and its meaning can beidentified based on its connection with thebehaviors, skills, or attributes believed to bean integral part of human life. Coding be-comes more specific as numbers are added toindicate levels of greater specificity. Forexample, b2 is a considered a first-level itemand refers to "body function, second chap-ter," which is "sensory functions and pain."b210 is a second-level item and is the codefor, "seeing functions." b2102 extends thespecificity to the third-level and now refersto "quality of vision." The fourth-level item,and most specific code is b21021, "colorvision." Tying this example of a code to TR,using code b21021, consider a TRS workingwith a person who has a visual impairment.Through the use of table or board games,sports where participants wear colored uni-forms or certain art projects, a TRS canevaluate an individual's vision and his or herability to differentiate or match colors [seeWHO, 2001, p. 62-3]. From this assessmenta TRS can advise activity modification toolsand offer assistance in coping with changesto one's style of participation in order tomaintain life satisfaction.
Body Structures and FunctionsBody structures and functions within the
ICF framework are identified in eight sections,called chapters. See Table 1 for a list of thesechapters. Within each of these chapters andtheir codes, the term impairment is used whenthere is a significant deviation, loss, or prob-lem in a body function or structure (WHO,2001). Within the ICF coding scheme, quali-fiers allow a practitioner to indicate the levelor severity of impairment from 0 (no impair-ment) to 4 (complete impairment). As indi-
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Table 1.
ICF: Body Functions and Structures Chapters
Chapter Body Functions Body Structures
Mental functionsSensory functions and painVoice and speech functions
Functions of thecardiovascular,hematological,immunological, andrespiratory systems
Functions of the digestive,metabolic, and endocrinesystems
Functions of the genitourinaryand reproductive systems
Structures of the nervous systemThe eye, ear, and related structuresStructures involved in voice and
speechStructures of the cardiovascular,
immunological, and respiratorysystems
Structures related to the digestive,metabolic, and endocrine systems
Structures related to the genitourinaryand reproductive systems
Structures related to movement
Skin and related structures
cated above in the example of vision, classifi-cation of codes (and corresponding therapeuticrecreation interventions) can be specific to thethird or fourth level. Identification of codeswithin this article, in most cases, does notexceed the second-level of classification.
Body functions and corresponding bodystructures are central to people's quality oflife. Other disciplines' scope of practice maymore directly focus their attention on bodyfunction (e.g. medicine, physical therapy,speech therapy). The TRS should be aware ofand realize the potential impact of TR serviceson specific body functions of clients, in addi-tion to realizing the interaction between bodyfunctions and important life events, includingrecreation and leisure functioning. Therefore,an awareness of body function codes and howthey are classified is important to the TR profes-sional (see Table 1). For each of the eight bodyfunction chapters of the ICF, a general statementof its relationship to TR practice is provided.
along with some specific examples. Given thelengthy list of relevant ICF codes to TR practice,space does not allow for example of each andevery code. It is hoped, however, that futuremanuscripts will further breakdown TR practicerelative to specific components of the ICF andprovide theoretical and important empirical re-search findings. BuUeted lists are provided forchapters with a large number of relevant codes,but for chapters where only a few codes aredeemed relevant to TR, these are included withinparagraph style.
Body Functions: Chapter 1—Mental Functions
Therapeutic recreation professionals shouldbe keenly aware and are often focused on assess-ing and improving the mental functioning ofclients. Mental functions of clients have a centralrole in how the TRS assesses and works withclients' strengths and weaknesses.
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Mental functions codes salient to TR are:
• Consciousness (bllO)—State of aware-ness and alertness.
• Orientation (bll4)—Knowing and as-certaining one's relation to self, to oth-ers, time, and surroundings.
• Intellectual (bll7)—Understanding andconstructive integration of all cognitivefunctions and their development over thelife span.
• Global psychosocial (bl22)—Integra-tion of mental functions that lead to theformation of interpersonal skills neededfor reciprocal social interactions.
• Temperament and personality(bl26)— Mental functions integral toconstitutional disposition of the individ-ual as they react to situations and formcharacteristics that makes the individualdistinct from others.
• Energy and drive (bl30)—Mental func-tions of physiological and psychologicalmechanisms that cause the individual tomove toward satisfying specific needs orgeneral goals in a persistent manner.
• Attention (bl40)—Focusing on an ex-ternal stimuli or internal experience for arequired period of time.
• Psychomotor functions (bl47)—Con-trol over both motor and psychologicalevents at the body level.
• Emotional functions (b 152)—Feelingand affective components of the pro-cesses of the mind.
• Perceptual functions (bl56)—Recog-nizing and interpreting sensory stimuli.
• Thought functions (b 160)—Mentalfunctions related to the ideational com-ponent of the mind.
• Higher-level cognitive functions (bl64)—Complex goal-directed behaviors such
as decision-making, abstract thinking,and planning.
• Mental functions of language (bl67)—Recognition and use of signs, symbols,and other components of language.
• Calculation (bl72)—Being able to de-termine, approximate, and manipulatemathematical symbols and processes.
• Mental function of sequencing com-plex movements (bl76)—Sequencingand coordinating complex, purposefulmovements.
• Experience of self and time (bl80)—Awareness of one's identity, one's body,one's position in the reality of one'senvironment and of time (bl801 bodyimage corresponds to mental functionsrelated to the representation and aware-ness of one's body).
As the majority of TR professionals workin settings where mental health and intellectualfunctioning is a central focus, outcomes of TRindeed encompass many, if not all, of the ICFcodes listed above. Generally-speaking, TRinterventions may include sensory stimulationto augment orientation and engagement, aswell as treatment activities that enhance cog-nition, memory, and the realization and appre-ciation of one's body and identity as an indi-vidual. In particular settings, other examplesinclude a TRS in a nursing home setting as-sessing an older person's level of conscious-ness and awareness of his or her surrounding,a TRS in a pediatric psychiatric facility pro-viding interventions to help youth becomeaware of their temperament and the affect oftheir personality on others, and/or a TRS in arehabilitation setting assisting a person whorecently had a stroke to releam language skillsor regain the ability to coordinate complexphysical movements.
Body Functions: Chapter 2—Sensory Functions and Fain
Sensory functions and the perception ofpain impact the quality of life of clients and
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affect the nature and scope of TR services thatare delivered. Participation in sports or games,communication with others during leisure ac-tivity, teaching a client meditation or guidedimagery techniques to cope with pain relatedto cancer, helping a client fully appreciate thesights, sounds, and smells of a trip to a localpark are all examples of the relevance of thischapter and its codes to TR practice.
Sensory functions and pain codes salient toTR are:
• Seeing (b210)—Sensing the presence oflight and the form, size, shape, and colorof visual stimuli.
• Hearing (b230)—Sensing the presenceof sounds and discriminating the loca-tion, pitch, loudness, and quality ofsounds.
• Vestibular (b235)—Functions of the in-ner ear related to position, balance, andmovement.
• Taste (b250)—Sensing qualities of bit-temess, sweetness, soumess, and salti-ness.
• Smell (b255)—Sensing odors and smells.
• Proprioceptive (b260)—Sensing therelative position of body parts.
• Touch (b265)—Sensing surfaces andtheir texture or quality.
• Sensory functions related to tempera-ture (b270)—Sensing temperature, vi-bration, pressure, and noxious stimulus.
• Sensation of pain (b280)—Sensation ofunpleasant feelings indicating potentialor actual damage to some body struc-ture.
Body Functions: Chapter 3—Voiceand Speech Functions
Vocal communication, since it is an inher-ent part of interpersonal interactions for mostpeople, is directly related to the quality ofexperiences people have as they carry outwork, family, and free-time activities. Voiceand speech functions are obviously relevant to
recreation, leisure, and sport participation. Im-pairments experienced in this area are of con-cem to the TRS and require him or her to assistthe client accordingly. Codes from this chapterlikely relevant to TR include:
• Voice functions (b310)—producing var-ious sounds by the passage of air throughthe larynx.
• Articulation (b320)—producing speechsounds.
• Fluency and rhythm of speech(b330)—producing flow and tempo ofspeech
• Alternative vocalization (b340)—pro-ducing other manners of vocalization).
Body Functions: Chapter 4—Functions of the
Cardiovascular SystemComponents of this chapter are applica-
ble to TR inasmuch as cardiovascular healthimpacts participation in recreation, leisure,sport as part of life. The TRS may assist theclient or other health care staff in monitoringheart rate (b4100), in addition to concernabout the maintenance of blood pressure(b4202), the immune system (b435), respi-ration rate (b4400), exercise tolerance(b455), general physical endurance (b4550),aerobic capacity (b4551), and fatigability(b4552). The treatment-oriented TRS mayinitiate interventions to increase aerobic ca-pacity and maintain a healthy blood pres-sure, while reducing fatigability. A TRS in acommunity-based health promotion setting,say perhaps working to address the coun-try's problem with obesity, may stress im-provements in exercise tolerance and phys-ical endurance. The body functions of thischapter are certainly significant for a TRSworking with people with AIDS whose im-mune system is compromised, or peoplewhose lives are impacted by chronic ob-structive pulmonary disorder (COPD).
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Body Functions: Chapter,Functions related to the
Digestive SystemComponents of this chapter are applicable
to TR inasmuch as the health and function ofthe digestive system is relevant to activitiesthat include shopping for food, cooking, eatingat home, eating out at restaurants, ethnic fes-tivals, or sports arenas; along with nutritionalaspects of diet that impact daily life and par-ticipation in recreation, leisure, and sports.Many TRS working in a variety of settingsconduct, for example, cooking groups, or con-duct community integration outings whereinan awareness of these components is neces-sary.
Digestive system functions codes salient toTR are:
• Ingestion (b510)—Taking in and manip-ulating solids or liquids through themouth into the body,
• Digestion (b515)—Transporting foodsthrough the gastrointestinal tract, break-down of food, and absorption of nutri-ents.
• Assimilation (b520)—Functions bywhich nutrients are converted into com-ponents of the living body.
• Defecation (b525)—functions of elimi-nation of waste and undigested food asfeces.
• Weight management (b530)—Main-taining appropriate body weight, includ-ing weight gain during the developmen-tal period.
• General metabolic functions (b540)—Regulation of essential components ofthe body such as carbohydrates, proteinsand fats, the conversion of one to theother, and their breakdown into energy.
• Maintenance of water balance(b54501)—Functions in maintaining op-timal amount of water in the body,
• Maintenance of body temperature(b5501) - Maintaining optimal body tem-
perature as environmental temperaturechanges.
Body Functions: Chapter 6—Genitourinary and Reproductive
FunctionsThis chapter is applicable to TR inasmuch
as genitourinary and reproductive function im-pacts the quality of life of clients, in additionto potentially impacting leisure or free timeactivity. As a normal human function, theprocess of eliminating bodily waste is relevantto all health care settings and professional caregivers. Likewise, sex is a basic human func-tion and concerns relative to sexuality, inti-mate relationships, and psychosocial and sex-ual issues of people with disabilities arerelevant to many populations the TRS workswith. Sex is typically a voluntary, free-timeactivity and many participate in sexual expres-sion for its attributes of recreation and rela-tionship enhancement. Also, because the TRSmay be approached by the client or the treat-ment team to ameliorate sexuality or intimacyproblems related to disability, the recreationtherapist should have competence and confi-dence to intervene appropriately. Codes withinthis ICF chapter salient to TR include: moni-toring urination (b620) and sexual functions(b640)—specifically sexual arousal phase(b6400), sexual preparatory phase (b6401), or-gasmic phase (b6402), and sexual resolution(b6403); menstruation (b650); and procreation(b660). As further examples, a TRS workingwith older adult populations is likely to en-counter men who have been diagnosed withprostate cancer. The treatment for prostatecancer often results in incontinence and erec-tile dysfunction. Each of these conditions,along with possible threats to masculinity, fa-tigue, embarrassment, anxiety, and/or depres-sion may impact many leisure and activities(e.g. travel, sports, exercise), including sexualrelationships (Howard, 2004). Also, the recre-ation therapist working in physical rehabilita-tion may encounter client issues telated toquality of life, social leisure, and community
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reintegration resulting from traumatic braininjury (Ponsford, 2003) or spinal cord injuries(Datillo, Caldwell, Lee, & Kleiber, 1998; El-liot, 2006; Lee & McCormick, 2006). Socialleisure may be considered an important part ofmeeting people and fortning relationships,some of which develop into ones includingintimacy and sexuality (Howard & Young,2002). Dealing with individuals with traumaticbrain injury or spinal cord injury often in-cludes coping with potential sexual dysfunc-tion or frustration (Howard & Nelson, 2005).
Body Functions: Chapter 7—Neuromusculoskeletal and
Movement-Related FunctionsThe ability of clients to move their body
within the context of accessing and participat-ing in recreation and leisure activities is ofgreat importance to the TR practitioner. Often,collaboration with other disciplines (such asphysical therapy) may occur when the TRSintroduces interventions that relate to struc-tures and functions identified within this chap-ter. Provision of recreation therapy in arehabilitation unit may focus on motor im-provement to allow for independent task per-formance or to increase muscle power, tone,and endurance, as well as improving jointmobility and fine and gross motor coordination(Andrews, Gerhart, & Hosack, 2004; Sell &Murrey, 2006),
Neuromusculoskeletal and movement-re-lated functions codes salient to TR are:
• Mobility of joint (b710)—Range andease of movement of a joint.
• Stability of joint (b715)—Maintenanceof structural integrity of the joints.
• Mobility of bone (b720)—Range andease of movement of the scapula, pelvis,carpal, and tarsal bones,
• Muscle power (b730)—Functions re-lated to the force generated by the con-traction of a muscle or muscle groups.
• Muscle tone (735)—Functions related totension present in the resting muscles
and the resistance offered when trying tomove the muscles passively,
• Muscle endurance (b740)—Sustainingmuscle contraction for the required pe-riod of time,
• Motor reflex (b750)—Involuntary con-traction of muscles automatically in-duced by specific stimuli.
• Involuntary movement reaction (b755)—Involuntary contractions of large mus-cles or the whole body induced by bodyposition, balance, and threatening stim-uli,
• Control of voluntary movement (b760)—Control over and coordination of vol-untary movements.
• Involuntary movement (b765)—Unin-tentional, non- or semi-purposive invol-untary contractions of a muscle or groupof muscles.
• Gait pattern (b770)—Movement pat-terns associated with walking, running,or other whole body movements.
• Sensations related to muscles andmovement (b780)—Sensations relatedwith the muscles or muscle groups of thebody and their movement.
Body Functions: Chapter 8—Functions of the Skin and related
StructuresComponents of this chapter are applicable
to TR inasmuch as the health of skin andrelated structures does relate to the functionand enjoyment of individuals during recre-ation, leisure, and play. The TRS should beinvolved in education and preventative mea-sures to ensure good health of the skin duringactivities, especially those that occur outsidein direct sunlight. In this instance, teachingclients to use sunscreen when outside is im-portant. Other examples are medication edu-cation and sun-sensitivity, the use of gloves orother protective measure, and proper hygieneafter exercise or participation in recreational or
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hobbies where the skin was exposed to dirt,paint, chemicals, or other potentially harmfulsubstances.
The reader should note that Body Struc-tures are listed in the ICF separately frombody functions and are identified with theirown codes, beginning with an "s." Referring tothe example used earlier about seeing func-tions, relevant body structure codes includethe structure of the eye socket (s210) and thestructure of the eyeball (s220), inclusive of thecornea (s2201), iris (s2202), retina (s2203),lens of eyeball (s2204), and vitreous body(s2205). Body structures are applicable totherapeutic recreation inasmuch as body struc-tures are implicitly part of body functionswhich allow participation in major life areassuch as employment, education, civic involve-ment, as well as recreation, leisure, sports,play, games, and other free-time activity.
Activities and ParticipationA major feature of the ICF, perhaps of
greatest importance to TR professionals, arethe activity and participation (A&P) sectionsof the ICF. The JCF describes activity as beingable to execute and complete tasks (e.g., read-ing, thinking, walking, dressing, solving prob-lems, interpersonal interactions, making deci-sions). Participation is defined as involvementin a life situation (e.g., going shopping, timespent on a hobby, dating, completing worktasks, volunteerism, renumerative employ-ment, attending a sporting event). Difficultiesexperienced while trying to perform tasks arecalled activity limitations. Participation re-strictions include any and all situations thatinterfere with participating in life events(WHO, 2001). In the ICF, A&P comprise ninechapters which are identified in Table 2,
The ICF coding scheme for A&P, similarto body functions and structure, provides forthe use of qualifiers after each A&P code toindicate the degree of problem being encoun-tered by the client (on a 0 = no problem to 4 =complete problem scale). Since 2002, leaderswithin the American Therapeutic Recreation
Table 2.
ICF: Activities and Participation Chapters
ChapterChapterChapterChapterChapterChapterChapter
ChapterChapter
1234567
89
Learning and applying knowledgeGeneral tasks and demandsCommunicationMobilitySelf-careDomestic lifeInterpersonal interactions and
relationshipsMajor life areasCommunity, social and civic life
Association (ATRA), along with other profes-sional membership organizations (e.g. physi-cal therapy, social work, occupational therapy)have assisted the American Psychological As-sociation in creation of the Procedural Manualand Guide for a Standardized Application ofthe ICF intended to help guide practitionersuse the ICF. This manual is expected to bepublished in 2007. As space will not allow forspecific examples pertaining to each code, foreach of the following chapters and the codeslisted within, the TR professional is encour-aged to identify and contemplate examples foreach A&P component salient to their specificsetting.
Activities & Participation: Chapter1—Learning and Applying
KnowledgeThe TRS is highly interested in the clients'
capacity and ability to learn information andapply that knowledge to important life situa-tions. A TRS may work in an alternative highschool settings may aim to increase basiclearning of student and the application of thatknowledge in other areas of life. A recreationtherapist in a correctional setting may workwith inmates preparing for parole to identifyrecreational or leisure interests and how he orshe can overcome barriers to the opportunities,resources, and facilities available to them forparticipation. This chapter includes three sub-
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sections that directly impact TR service deliv-ery. These are:
• Basic learning including copying(dl30), rehearsing (dl35), learning to read(dl40), learning to write (dl45), learningto calculate (dl50), and acquiring skills(dl55)—either basic or complex.
• Applying knowledge including focusingattention (dl60), thinking (dl63), read-ing (dl66), writing (dl70), calculating(dl72), solving problems (dl75)—sim-ple or complex, and making decisions(dl77).
Activities & Participation: Chapter2—General Tasks and DemandsThis chapter pertains to general aspects of
carrying out single or multiple tasks, organiz-ing routines, and handling stress. These itemscan be conceptualized in conjunction withmore specific tasks or as actions to help iden-tify the underlying features of tasks withindifferent circumstances. Salient codes to TRwithin this chapter include:
• Undertaking a single task (d210)—whether it is simple (d2100), complex(d2101), undertaken independently(d2102), or in a group (d2103).
• Undertaking multiple tasks (d220)—including elements of carrying out(d2200) or completing (d2201) multipletasks.
• Carrying out daily routine (d230)—including managing (d2301) or complet-ing (d2302) the daily routine or one'sown activity level (d2303)
• Handling stress and other psychologi-cal demands (d240)—inclusive of han-dling responsibilities (d2400), handlingstress (d2401), or handling a crisis(d2402).
The latter code is often relevant to stressmanagement groups, often conducted by TRprofessionals in both clinical and communitysettings. Specifically, a TRS may utilize dif-ferent modalities or relaxation techniques (e.g.deep breathing, progressive muscle relaxation,biofeedback training, or imagery/visualiza-tion). As the TRS works in a myriad of settingsthat address an individual's general tasks anddemands, a central role of the recreation ther-apist is to improve functional abilities andindependence in life activities.
This chapter of the ICF is about generaland specific features of communication. Spe-cific codes most significant to TR include:
• Communicating with and receivingspoken message (d3IO)
• Communicating with and receivingnonverbal messages (d315)
• Communicating with and receivingsign language messages (d320)
• Communicating with and receivingwritten messages (d325)
• Speaking (d330)
• Producing nonverbal messages (d335)
• Producing messages in formal signlanguage (d340)
• Writing messages (d345)
• Conversation (d350)—Inclusive ofstarting (d3500), sustaining (d3501), andending (d3502) a conversation; convers-ing with one person (d3503) or manypeople (d3504).
• Discussion (d355)—With one person(d355O) or many people (d3551)
• Using communication devices andtechniques (d360).
Conversation is an integral part of socialskills training that the TRS often focuses on -specifically, starting a conversation (d3500).
First Quarter 2007 71
sustaining a conversation (d3501), ending aconversation (d3502), or conversing with oneperson (d3503) or many people (d3504). As aspecific example, the TR working with youngchildren with developmental disabilities, mayutilize scripted play as a language intervention(Neeley, Neeley, Justen III, & Tipton-Sumner,2001).
Activities & Participation: Chapter4—Mobility
This chapter contains information relativeto people moving through changing body po-sition or location or by transferring from oneplace to another. It is highly important for theTRS to identify and take into considerationthese components as activities germane to ba-sic daily tasks, meaningful participation insignificant areas of life, as well as the rele-vance of many of these chapter codes withinmany, if not most, recreation and leisure ac-tivities. Any TR practitioner whose scope ofpractice includes interventions that focus onoutcomes that include or result in body mo-tion, should be aware of this chapter and itsfour sections:
• Changing and maintaining basic bodyposition (d410) including: lying down(d4100), squatting, (d4101), kneeling(d4102), sitting (d4103), standing(d4104), bending (d4105), and shiftingthe body's center of gravity (d4106);maintaining a body position (d415), andtransferring oneself (d420).
• Carrying, moving, and handling ob-jects including: lifting and carrying ob-jects (d430), moving objects with lowerextremities (d435), fine hand use (d440),and hand and arm use (d445).
• Walking and moving including: walk-ing (d450)—including short distances(d4500), long distances (d4501), on dif-ferent surfaces (d4502), and around ob-stacles (d4503); moving around (d455)—including climbing (d4551), running(d4552), jumping (d4553), and swimming
(d4554); moving around in different loca-tions (d460), and moving around usingequipment (d465).
• Moving around using transportationincluding: using transportation (d470)—as a passenger, using human-powered ve-hicles (d4700), private motorized (d4701),or public transportation (d4702); driving(d475), and riding animals for transporta-tion (d480).
Activities & Participation: Chapter5—Self-Care
This chapter pertains to activities done forself-care and the TRS may participate in educa-tional activities (perhaps in collaboration withthe nursing department or occupational therapy).These codes include: washing oneself (d510),caring for body parts (d520), toileting (d530),dressing (d540), eating (d550), drinking (d560),and looking after one's health (d570). At aminimum, a TRS likely takes part in educatinga client about the importance of washing one-self and caring for the body after physicalactivities (e.g. exercise, gardening) or how toappropriately dress for participation in eventstaking place in formal vs. casual settings, or incold vs. hot weather.
Activities & Participation: Chapter6—Domestic
This chapter is applicable to the practiceand work of TR professionals inasmuch asdomestic life (e.g., acquiring a place to life(d601), acquisition of goods and services (d620),preparing meals (d630), doing housework(d640), caring for household objects d650), andassisting others (d660)) is connected to signifi-cant activities, inclusive of those done within thecontext of recreation, leisure, and play.
Activities & Participation: Chapter7—Interpersonal Interactions and
Relationships
This chapter is highly salient to TR pro-fessional practice as it relates to tasks and
72 Therapeutic Recreation Journal
actions of their clients required for basic andcomplex interactions with other people in acontextually and socially appropriate man-ner. The TRS is often asked to facilitatesocial skills interventions where clients aretaught how to create, maintain, and enhancerelationships with family, friends, col-leagues, and others with whom they mayinteract in the course of day-to-day life. Thechapter's two sections are:
• General interpersonal interactionsincluding: basic interpersonal interac-tions (b710)—including respect andwarmth (d7100), appreciation (d7101),tolerance (d7102), criticism (d7103),social cues (d7104), and physical con-tact (d7105); complex interpersonal in-teractions (d720)—including formingrelationships (d7200), terminating rela-tionships (d7201), regulating behaviorwithin interactions (d7202), interactingwithin social rules (d7203), and main-taining social space (d7204),
• Particular interpersonal relationshipsincluding: relating with strangers (b730),formal relationships (b740)—with per-son of authority (d7400), with subordi-nates (d7401), with equals (d7402);informal social relationships (d750)—with friends (d7500), neighbors (d7501),acquaintances (d7502), co-inhabitants(d7503), and peers (d7504); family rela-tionships (d760)—including parent-child(d7600), child-parent (d7601), sibling re-lationships (d7602), and extended family(d7603); intimate relationships (b770)—including romantic (d7700), spousal(d7701), and sexual (d7702).
Activities & Participation: Chapter8—Major Life Areas
This chapter is applicable to TR inasmuchas major life areas (e.g., education, work andemployment, and economics) create and relateto the context within which recreation, leisure.
and play activity exists. Items in this chapterpertain to carrying out tasks and actions re-quired to engage and benefit from educationand employment, as well as conducting eco-nomic transactions. Codes potentially salientto therapeutic recreation and the livelihoodsought for clients include: acquiring, keeping,and terminating a job (d845). As an essentialpart of successful community integration, theTR may need to teach skills associated withbasic (d860) or complex economic transac-tions (d865) and economic self-sufficiency(d870) inclusive of personal resources (d8700)and public entitlements (d8701).
Activities & Participation: Chapter9—Community, Social, and Civic
LifeThis chapter pertains to actions and tasks
required to engage in organized life outside thefamily, within the community, and in socialand civic areas of life. Salient areas include:community life (d910), recreation and leisure(d920), religion and spirituality (d930), humanrights (d940), and political life and citizenship(d950). Of likely interest to the TR profes-sional, d920 recreation and leisure is furtherspecified in terms of play (d9200), sports(d9201), arts and culture (d9202), crafts(d9203), hobbies (d9204), and socializing(d9205). Leisure education may likely includethe assessment of leisure motivations and in-terests and participation satisfaction.
Personal and EnvironmentalFactors
Within the ICF are two types of contextualfactors - environmental and personal. Personalfactors include characteristics and phenomenathat may potentially impact or influence anindividuals' health or experience with disease,disability, or disabling condition. Some ofthese personal factors include: gender, race,age, fitness, lifestyle, behavioral patterns orhabits, upbringing, religion, sexual orientation,coping styles, social background, economic(dis)advantages, education, profession, life ex-
First Quarter 2007 73
Table 3.
ICF: Environmental Factors Chapters
Chapter 1 Products and technologyChapter 2 Natural environment and
human-made changes toenvironment
Chapter 3 Support and relationshipsChapter 4 AttitudesChapter 5 Services, systems, and policies
periences (past, present, goals/dreams for thefuture), and individual psychological and per-sonality traits. Because of the large social andcultural variations associated with them, per-sonal factors are not classified or given codesin the ICF. Discussion is occurring, however,that may see classification of personal factorswithin future editions of the ICF (Badley,2006), Personal factors are important to thehealth and perceived quality of life of a client.One example is now offered. In illustration ofhow personal factors interact with other com-ponents of the ICF (e,g. A&P Chapter 6:Domestic Life), the TRS may be aware ofbarriers to recreation and leisure for womenchallenged by pressure to complete domesticduties at the expense of meaningful free-timeinvolvement (Shaw, 1999), or in light ofchanging employment demographics that havewomen working more outside the home whilemaintaining traditional levels of responsibilitywithin the home (Kay, 1996).
Environmental factors are classified withinfive chapters listed in Table 3. It is significantto note that environmental factors can be qual-ified as either a barrier or a facilitator, whereasother ICF codes are currently qualified nega-tively as impairments (body functions andstructures) or difficulties (activities and partic-ipation). The opportunity to indicate environ-mental factors as facilitators allows the healthcare professional to identify strengths and pos-itives that contribute to the health of an indi-vidual or client (WHO, 2001).
Environmental Factors: Chapter 1—Products and technology
Several product and technology codes areapplicable to TR since these classify aspectsused to facilitate a person's participation inrecreation, leisure, and play (e.g. daily living,mobility, or communication). Of particular in-terest is e]40: Products and technology forculture, recreation, and sport which includethe use of adapted or specifically designedequipment, products, and technology. Porterand burlingame (2006) include a list of twen-ty-four types of equipment within their hand-book of ICF-based TR practice. Other codes ofpotential relevance to the provision of TRservices include products/substance and/ortechnology for personal: consumption (el 10),use in daily living (el 15), and indoor andoutdoor mobility and transportation (el20).Further, codes exist for either general or as-sistive products and technology for: commu-nication (el25), education (el30), employ-ment (el35), the practice of religion andspirituality (el45), the design and constructionof buildings for public (el 50) or private (el 55)use, and relative to land development (el60)rural, suburban, or urban.
Environmental Factors: Chapter 2—Natural environment and human-
made changes to environmentInformation within this chapter is applica-
ble inasmuch as the natural environment andhuman-made changes to one's environmentcan greatly impact and interact with an indi-vidual's experience, inclusive of participationin recreation, leisure, play, and sports. Salientaspects of this chapter include: physical geog-raphy (e210), population (e215), plants andanimals (e220), climate (e225), natural events(e230), human-caused events (e235), light(e240), time-related changes (e245), sound(e250), vibration (e255), and air quality(e260).
74 Therapeutic Recreation Journal
Environmental Factors: Chapter 3—Support and relationships
This chapter is highly applicable to TRpractice given that interpersonal relationshipsare often deemed a crucial part of life andmany recreation, leisure, and play experiences.Recreation therapists may facilitate and assistphysical and emotional support (including theuse animals) and interpersonal relationshipsfor clients in health care settings. Community-based TR professionals may seek to create orenhance social support, tolerance, and cooper-ation within neighborhoods and cities. Specificcodes exist pertaining to immediate family(e310), extended family (e315), friends(e320), acquaintances, peers, neighbors(e325), people in positions of authority (e330),people in subordinate positions (e335), per-sonal care providers and personal assistants(e340), strangers (e345), domesticated animals(e350), health professionals (e355), and otherprofessionals (e36O).
Environmental Factors:Chapter 4—Attitudes
This chapter is about the attitudes that existas observable consequences of customs, ideol-ogies, values, norms, scientific beliefs, reli-gious beliefs, and practices within one's soci-ety. This is highly applicable to TR becauseattitudes related to family (e410), friends(e420), people in positions of authority (e430),personal care providers (e440), strangers(e445), in addition to societal attitudes (e460)and social norms (e465) impact the employ-ment, education, religious, and cultural fabricof our communities. Attitudes as a factor ofhuman experience also can impact recreation,leisure, and play experience of all people,especially those with disabilities that may neg-atively experience stigma, discrimination,and/or stereotype (Bedini, 1998; Smart, 2000).
Environmental Factors: Chapter.Services, systems, and policies
Services, systems, and policies (regardingconsumer goods, architecture and construc-
tion, open space, housing, utilities, communi-cation, transportation, civil protection, legal,associations and organizations, the media, so-cial security, general social supports, healthservices, education and training, employment,and politics) impact human life and a person'sability to learn about, access, and fully partic-ipate in recreation, leisure, and play experi-ences of their choosing. Of possible interest,the TR professional will find recreation andleisure specifically mentioned within openspace planning (e520), and associations andorganizational services (e555). e580 Healthservices, systems, and policies is relevant tothe need for societies to create and maintainthe resources needed to prevent and treathealth problems, provide medical rehabilita-tion, and promote a healthy lifestyle for itscitizenry.
Disease, Population, and Setting-Specific Core Sets
The reader is encouraged to seek and uti-lize information about disease and population-specific ICF "core sets" that have been createdand published utilizing "linking rules" estab-lished to connect technical and clinical mea-sures, health-status measures and interventionsto the ICF (Cieza et al,, 2005), To alleviatepossible confusion of the reader, health caredisciplines, may create "code sets" to aligntheir professional practice with the ICF (as isintended in this article). However, "core sets"is the term found in the literature when ICFcodes are identified describing facets of healthconditions relative to diseases or a specifichuman population.
These core set manuscripts identify impor-tant aspects of a person's experience with ahealth condition, linked to ICF categories ofbody structures, body functions, activities andparticipation, and environmental factors. Theprocess of developing a core set is a stringentone and, as illustrated in a recent manuscriptproviding a core set for spinal cord injury,included the following steps: empirical study,focus groups, expert survey, systematic re-
First Quarter 2007 75
view, and an ICF core set consensus confer-ence (Biering-Soresen et al., 2006), Using auniversity or public library computer system,search engines such as PubMed or Medlineprovide resources about the use and applica-bility of the ICF to practice settings where TRprofessionals work. For this article, using bothMedline and Pubmed database search engines,a literature search resulted in finding numerousarticles linking the ICF to certain disease ordisabling conditions.
Listed in alphabetical order, these manu-scripts are identified as introducing a core setshowing ICF components applicable to thefollowing diseases or conditions:
The following manuscripts describe at-tributes of diagnosis and treatment relative tocertain populations to the ICF:
• Assessment of deafblindness (Moller,2003)
• Cerebral palsy (Rosenbaum & Stewart,2004)
• Childhood disability (Simeonsson etal., 2003)
• Children with cognitive, motor, andcomplex disabilities (Battaglia et al.,2004)
• Chronic conditions (Cieza, Ewert et al.,2004)
• Common disease conditions (Grimby,Harms-Ringdahl, Morgell, Nordenski-old, & Sunnerhagen, 2005)
• Communication disabilities in chil-dren (Simeonsson, 2003)
• Geriatric care (Okuchi, Utsunomiya, &Takayashi, 2005)
• Geriatric patients in early post-acuterehabilitation facilities (Grill, Stucki,Boldt, Joisten, & Swoboda, 2005)
• Human behavior (Wade & Halligan,2003)
• Severe disability (Bomman, 2004)
• Stuttering (Yaruss & Quesal, 2004)
It may interest the reader to note the ICFhas been examined as a tool to assist in clas-sifying the impact of human disasters (e.g. theattacks on the World Trade Center and Penta-gon) (Seltser, Dicowden, & Hendershot,2003). The following articles link the ICF onlyto specific treatment settings or facilities or
76 Therapeutic Recreation Journal
health issue: acute hospital settings (Grill, Hu-ber et al., 2005), acute hospital and earlypost-acute rehabilitation (Grill, Ewert, Chat-terji, Kostanjsek, & Stucki, 2005), early post-acute rehabilitation -comparison of the ICFwith three functional measures (Grill, Stucki,Scheuringer, & Melvin, 2006), and functionalstatus information in health records (Ustlin,Chatterji, Kostansjek, & Bickenbach, 2003).
Other articles linking the ICF to health-related issues of potential interest to the TRprofessional include: the Intemational Disabil-ity Rights movement (Hurst, 2003), medicine(Stucki & Grimby, 2004), rehabilitation med-icine (Stucki, 2005), and work-capacity as-sessment and back-to-work predictors (Schult& Ekholm, 2006), It should also be noted thata special version of the ICF, based on chil-dren's unique characteristics and developmen-tal needs, has been created (Lollar & Simeons-son, 2005) and is accessible on-line (WHO,2007). TR practitioners who work with chil-dren can therefore use the ICF-CY to classifytheir practice efforts. Furthermore, signs indi-cate greater application of ICF concepts andcomponents within the formation of assess-ment instruments, the creation of programsand health care strategies, and potentially, re-imbursement and compensation systems. AsTR professionals, we can begin by "cross-walking" our assessments, job descriptions,recreation and leisure activities, interventions,and standards of practice with the ICF.
Conclusion and Future DirectionsThe ICF presents an excellent framework
to describe and conceptualize TR practice.Within this article, we hope to have demon-strated how TR practice fits with the ICFmodel of health and its classification system.The body function chapters and, in particular,codes associated with activities and participa-tion within the ICF have great relevance tofunctional outcomes sought for by recreationtherapists in clinical settings, along with ob-jectives related to health promotion, inclusion,and health education salient to all TR profes-
sionals. The ICF does indeed describe humanfunctioning in all settings, and is not justapplicable to health care service and settings.Therefore, the ICF provides TR professionalswith a conceptual framework to link theirprofession practice in any and all settings witha globally-accepted taxonomy.
It is anticipated that the ICF will create anopportunity for greater awareness of TR ser-vices. As a discipline, TR has much to offer.Therapeutic recreation must be part of futurediscussion and the further development of theICF and its potential to revolutionize the par-adigm of health care and health promotionthroughout the world. Doing so will mosteasily occur when TR practice is, first, shownto be aligned with the WHO's holistic view ofhealth and disability; and second, is exempli-fied when TR adopts and uses the commonlanguage, terms, and definitions of the ICF inconcert with other health professionals work-ing collaboratively to address the broad needsof people with disabilities. To this end, theATRA Public Health-WHO Team has existedfor four years striving to meet important goalsand objectives. Some of these include educat-ing members through presentations at nationaland regional conferences (approximately fif-teen the past four years), attending and pre-senting at North America Collaborating Centerconferences on the ICF (Howard, 2006; Mc-Cormick et al., 2004), participating in theediting, review, and publication of the APAclinical manual, and presenting TR at intema-tional conferences (Howard & Browning,2005).
It is hoped that all TR professionals, in-cluding other professional organizations suchas NTRS, will become more actively involvedin ensuring that TR services in clinical andcommunity settings thrive, in large part, basedon an infusion of the ICF within TR practice.The ICF lays the framework for establishing acomprehensive and scientific basis for under-standing and affecting health and health out-comes. It provides a common language toimprove communication at all levels of healthand society, along with supporting comparison
First Quarter 2007 77
of data across the world, within and betweenhealth care disciplines, and relative to health-related services. The ICF provides a system-atic coding scheme for health information. TheTR profession should be consciousness of ef-forts relative to the globalization of health aswe communicate our body of knowledge withothers, i.e., those outside of our nation and ourprofession. In an increasingly global society,the TR profession needs to be connected withallied health professions, nationally and inter-nationally, through conceptual frameworkssuch as the ICF that describe health and humanfunction. This will help to systematically andeffectively guide clinical practice, research,and the development of social policy that pro-mote better health for all.
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