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Review on ICF-related Research Trends in Korean Clinical Field
J Korean Soc Phys Med 2021;16(4):33-44
Published online November 30, 2021;  https://doi.org/10.13066/kspm.2021.16.4.33
© 2021 Journal of The Korean Society of Physical Medicine.

Ju-Min Song , PT, PhD

Department of Physical Therapy, Silla University
Received September 16, 2021; Revised September 17, 2021; Accepted October 12, 2021.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
PURPOSE: This study analyzed the research trends related to the International Classification of Functioning, Disability, and Health (ICF) to suggest an ICF utilization plan in the Korean clinical field.
METHODS: In the RISS, KISS, NSDL, and PubMed databases, papers published between 2016 and July 2021 were collected by applying the search terms, ‘ICF’, ‘international classification of functioning, disability and health’, ‘clinic’, ‘patient’, and ‘diagno’. The 44 papers selected were classified according to the analysis criteria, and the frequency and percentage were calculated.
RESULTS: In domestic clinical trials, the frequency of ICF-related studies was in the order of physical therapy (n = 19) and occupational therapy (n = 14). The frequency of each study subject was observed in the order of studies related to a specific disease (n = 34) and prior studies (n = 7). The research topics were in the order of studies using ICF as a measurement tool (n = 21) and case studies with patients with specific diseases (n = 11). There were 18 studies using ICF codes and 14 papers applying the ICF domains.
CONCLUSION: Over the last five years, ICF-related research in the domestic clinical field targeted patients with more diverse diseases in more expertise fields. Research for the unification of terms should be conducted for communication among various experts in clinical practice. To promote the use of ICF in the clinical field, it will be necessary to conduct research, such as the unification of terms, standardized education, development of ICF casebook, and development of ICF coding programs and guidelines.
Keywords : Clinical field, Disability, Functioning, ICF
Ⅰ. Introduction

Functioning is an umbrella term that expresses the degree of an individual's physiological function, anatomical structure, ability to perform daily living, and participation in various areas of life. It interacts with environmental factors that affect individual and personal factors, including age, gender, and health status, and can indicate the degree of limitations and restrictions around life in which the person lives [1,2].

An evaluation of functioning is generally performed in the clinical field for a diagnosis of disease, treatment planning, evaluation of the treatment effect, and identification of disability. In addition, functioning-related information is essential at all levels of the medical system, such as treatment, service revision, management, and policy. Therefore, the degree of functioning should be evaluated from various aspects [3].

The World Health Organization recognized the need for a model and information system that can explain the effects of disease on functioning, and published the ICF in 2001. It is based on a biopsychosocial model that consists of the body function and structure, activity and participation, and environmental factors. Hence, health and health- related information can be classified from multiple perspectives. The four domains interact and affect the degree of an individual's functioning and disability [1]. Each domain is composed of chapters that include two-level and three-level codes below it. The three-level code, which is the lowest structure, can express more detailed information. Qualifiers from 0 to 4 written after a code can indicate the degree of difficulty, barrier, and facilitation of that code [4,5].

ICF is being used as a common language to communicate functioning-related information among users in various fields, such as health professionals, researchers, policymakers, and educators [6]. It is becoming common for clinicians to use the ICF framework to classify functioning information and structure treatment goals [7].

Since ICF was developed in 2001, ICF-related research on various topics has been reported in various fields. Recently, ICF-related research has focused mainly on the validity of the ICF core set, development of a new functioning evaluation tool, and development of a core set appropriate for the situation of the country, how to use ICF for better understanding and correct use of ICF [2,8-10]. Research on how to use ICF is essential because it can seek ways to understand ICF properly and apply it correctly. Through trend analysis of related prior research, it is possible to determine an application plan in the process of presenting research problems and research directions. In addition, such a utilization plan should be devised to maintain the character of a standard classification while reflecting the characteristics of the country or specialized field.

ICF-related research is being conducted in various fields in Korea. Most research has been reported in the clinical field [11,12]. In the clinical field, studies have been performed on the following: to evaluate the change in a patient's functioning before and after treatment, review previous ICF studies, develop and analyze an evaluation tool using ICF, and confirm the possibility of applying ICF and apply methods. Case studies are presented. On the other hand, there are insufficient reports on ICF-related research trends and ICF utilization plans in the clinical field. In the clinical area, it can be helpful to find ways to promote the use of ICF by examining the usage trends of which level or type used ICF for what purpose. Therefore, this study examined the trends of ICF-related research in the domestic clinical field to suggest a plan to utilize ICF to be used actively as a standard classification in the clinical field.

Ⅱ. Methods

1. Search Methods and Selection Criteria for Subjects

A literature search was conducted for four weeks from July 2021 to investigate the trend of ICF-related research in the domestic clinical field. As domestic databases, RISS of the Korea Education and Research Information Service, KISS of Korean Studies Information, and NDSL of National Digital Science Library were used.

The search terms used for the literature search were ‘ICF’, ‘international classification of functioning, disability and health’, and ‘국제기능장애건강분류’, and the operator ‘or’ was used between them.

In the papers collected, papers with ‘clinic’, ‘patient’, ‘diagnos’, ‘clinical’, ‘patient’, or ‘diagnosis’ in the title, abstract, and keywords were selected. PubMed was used to search for papers published in foreign journals, and the search term ‘Korean’ was added to proceed in the same manner as in the domestic database.

The inclusion criteria for the selection of papers for this study are as follows. First, the papers have a title, an abstract, or a keyword that includes these search terms. Second, among the papers published from 2016 to July 2021, the ICF was applied, and the studies were conducted in Korea and included Korean authors. Third, in the case of papers published in Korea, they appeared in journals registered in the National Research Foundation of Korea and candidate journals that require peer-review. Fourth, the papers were published within the last five years.

Studies that met the following exclusion criteria were excluded: papers, in which “ICF” does not mean “international classification of functioning, disability and health”; articles published in journals other than those registered in the National Research Foundation of Korea and candidate journals; studies that do not apply the ICF framework or codes; and publications in foreign clinical settings, though they were published in either of the aforementioned domestic journals.

During this period, 88 papers (51 from RISS, 18 from KISS, 16 from NDSL, and three from PubMed. were collected after a search using the suggested keywords. After deleting 37 duplicate papers, the abstracts and texts of 44 papers were read to confirm the inclusion and exclusion criteria.

Forty-four papers were selected as research subjects, excluding the following papers: three papers where ICF does not mean ‘international classification of functioning, disability and health’, one thesis for students with disabilities in the field of special education, one paper including clinical analysis in the ICF core-set utilization trend analysis study, one systematic review of dementia patients in the field of social welfare, and one paper on an investigation of the correlations related to stroke patients.

2. Analysis Criteria for Subjects

For the analysis of the selected papers, the analysis framework reported in previous studies was modified and applied [11,12]. A coding process was carried out for the title of the paper, researcher's area of expertise, type of research subjects, level of ICF applied in the study, domains of the ICF used in the study, research topic, year of publication, names of the researchers, and the name of the published journal and main issue.

Based on the coding contents, the selected papers were classified into oriental medicine, medical information, neurology, occupational therapy, otolaryngology, physical therapy, and rehabilitation medicine according to the area of expertise of the principal researcher, and the frequency was confirmed. The types of study subjects were divided into patients, prior thesis, expert, and insurance fee. In studies where the subjects were patients, patients were classified by disease-related body system.

Research topics were classified into an evaluation of functioning using ICF, a case study of applying ICF, review on ICF, tool development using ICF, analysis of existing measurement tools using ICF, treatment planning using ICF, and insurance fee analysis using ICF. The studies that evaluated subjects for measurement tool analysis or development were processed in duplicate in the evaluation, tool analysis, and development.

The ICF domains used in the study subjects were classified into the physical function, physical structure, activity and participation, and environmental factors. The level of ICF applied in the research paper was classified into the ICF domain and ICF code, and the type of ICF was classified into ICF core set and ICF tool. In addition, the application of WHODAS 2.0, which was made based on ICF, was also classified.

3. Data Analysis

Data analysis was conducted by summing the number of research papers according to the analysis criteria for coded data. Some research topics and the ICF domain used were classified by multiple analysis criteria, so duplicate frequencies were allowed in the data. The organized data were analyzed with the IBM SPSS 23 using multiple response cross-tabulation analysis for frequency and case percentages.

Ⅲ. Result

1. Analysis by Area of Expertise

Over the past five years, many studies related to ICF have been conducted in the order of physical therapy (19 articles, 43.2%), occupational therapy (14 articles, 31.8%), and rehabilitation medicine (6 articles, 13.6%) in domestic clinical field (Fig. 1, Annex 1).

Fig. 1. Number of studies published according to the expertise field in domestic clinical research related to ICF.

2. Analysis by Study Subject

The subjects of the selected papers were mostly patients (n = 34, 77.3%), followed in order by previous studies (n = 7, 15.9%), and related experts (n = 2, 4.5%) (Fig. 2). Papers on patients classified the diseases according to the body system. As a result, nervous system patients (n = 22, 50%) were the most common. Of these patients, stroke (n = 15, 34.1%) was the most common, followed by spinal cord injury (n = 2, 2.3%). Cerebral palsy, Parkinson's disease, dementia, peripheral nerve injury, and psychiatric patients were also classified as nervous system patients.

Fig. 2. Types and number of ICF-related research topics according to the field of expertise in domestic clinical research (pt.: patient).

Fig. 3. Levels and types of ICF used in articles published according to the field of expertise in domestic clinical fields.

There were eight studies targeting patients with the musculoskeletal system, accounting for 18.2% of the total. Back pain, shoulder pain, neck pain, temporomandibular joint pain, adhesive capsulitis, rotator cuff tear, multiple knee ligament injury, and scoliosis were also included in musculoskeletal system patients. In the respiratory system patients, one patient each of the pharyngeal, larynx, and benign mucosal diseases related to the vocal organs was observed. In the preceding papers that were the subject of the review study, one paper each was related to stroke (n = 3) and cerebral palsy (n = 2), and dementia and specific treatment-related papers were identified. In the preceding papers reviewed, there were three and two papers on stroke and cerebral palsy, respectively, and one paper each related to dementia and specific treatment was identified.

3. Analysis by Research Topic

The most common research subjects used ICF as a measurement tool (n = 21, 47.7%) to evaluate the functioning level and characteristics of the study subjects, followed in order by ICF case studies (n = 11, 25%) and review studies related to ICF targeting a specific disease (n = 8, 18.2%). For the analysis of the functioning measurement tool, the five studies that performed the subject's evaluation were duplicated in the study using ICF as a measurement tool and the measurement tool analysis. Table 1 lists the research topics for each expertise area.

Types and Number of ICF Research Topics Used in Each Expertise Area in Domestic Clinical Research Related to ICF * number (%)

Measurement tool Tool development Case study Tool analysis Intervention plan Review Insurance big data Total by area
Physical therapy 11(42.3)* 2(7.7) 9(34.6) 4(15.4) 26(59.1)
Occupational therapy 3(21.4) 2(14.3) 1(7.1) 7(50.0) 1(7.1) 14(31.9)
Rehabilitation medicine 4(66.67) 1(16.7) 1(16.7) 6(13.6)
Otorhinolaryngology 2(66.7) 1(33.)3 3
Neurology 1(100) 1
Korean medicine 1(100.0) 1
Medical information 1(100.0) 1
Total 21(47.7) 6(54.5) 11(25.0) 4(9.1) 1(2.3) 8(18.2) 1(2.3) 44(100.0)


4. Analysis according to the Domain of ICF Utilized

Table 2 lists the overlapping analysis of the ICF components used in the selected ICF-related domestic studies. The most used domain was activity and participation with 43 cases (40.9%), followed by the body function domain with 33 cases (30.8%).

Types and Number of ICF Domains Used in Each Expertise Area in Domestic Clinical Articles (Duplicate Frequency) * number (%)

Body function Body structure Activity & Participation Environmental factor Total by area
Physical therapy 14(31.1)* 4(8.9) 19(42.2) 8(17.8) 45(42.1)
Occupational therapy 12(33.3) 2(5.6) 13(36.1) 9(25.0) 36(33.6)
Rehabilitation medicine 4(26.7) 3(20.0) 6(40.0) 2(13.3) 15(14.0)
Otorhinolaryngology 2(100.0) 2(1.9)
Neurology 1(50.0) 1(50.0) 2(1.9)
Korean medicine 1(25.0) 1(25.0) 1(25.0) 1(25.0) 4(3.7)
Medical information 1(33.3) 1(33.3) 1(33.3) 3(2.8)
Total 33(30.8) 10(9.3) 43(40.2) 21(19.6) 107(100)


5. Analysis according to the Level and Type of ICF Utilized

In the research papers of this study, ICF codes (n = 18, 40.9%) were used more than the ICF domain (n = 14, 31.8%). As for the ICF type, the ICF core set (n = 7, 15.9%) and ICF tool (n = 3, 6.8%) were observed.

Ⅳ. Discussion

This study examined the trends of ICF-related research conducted in the domestic clinical field to suggest a utilization plan that can be used actively as a standard classification in the clinical field. This study analyzed the papers that met the inclusion criteria among research papers reported in the clinical field over the past five years. The research papers were analyzed after classifying them into specialized areas, research subjects, research topics, used ICF domains, and used ICF levels and types. The following discussions can be made based on the results obtained.

Physical therapy was the specialty of the clinical field, where ICF-related research was conducted the most, followed by occupational therapy and rehabilitation medicine. This was like the results of previous studies [11,12]. These results were attributed to the collection of functioning-related information to understand the patient's health condition and disability in these areas and the use of ICF for this purpose [13,14]. In many clinical settings, physical therapy is an important part of a multidisciplinary rehabilitation setting that aims to encourage individuals with health conditions to achieve and maintain the optimal functioning and encourage full participation of individuals in all aspects of life in their environment [15]. Hence, it is believed that the use of ICF in physical therapy was the most common. Research on otolaryngology and Korean medicine, which were not observed in previous studies, was reported, which means that the field of expertise for conducting ICF-related research is expanding [16,17].

The papers analyzed in this study mostly involved nervous system patients, such as stroke, spinal cord injury, and dementia. These results are like those of previous studies [18], and it is believed that ICF-related studies were mainly conducted in a rehabilitation setting, including physical therapy and occupational therapy. Many studies were conducted on stroke patients because stroke is one of the most disabling conditions caused by impairments of the body functions and structures, limitation of activities, and restriction of participation due to loss of neurological function [19,20]. Overall, communication of functioning performance-related information using ICF among experts will be more active if more diverse types of patients are examined.

Most research subjects using ICF to evaluate patients' functioning and characteristics were similar to previous studies [11,12]. This reflects the characteristics of the clinical field and is an essential part of understanding the patient's health condition.

Case study topics for various diseases were observed in physical therapy, and this trend was like that of previous studies. In these studies, ICF was used for patient intervention goals, planning, evaluation, and prognosis [21-23]. Moreover, readers can easily apply ICF to patient treatment and evaluation using these case studies.

Research topics that analyze the tool by linking the concept contained in the items of the functioning measurement tool into ICF code, which is typically used in the physical therapy area, and the research topic that confirms the possibility of coding by linking the contents of the medical records into ICF code were also observed [24-27]. If the existing measurement tool relates to the international standard classification, ICF, communication between experts can be facilitated, and data comparison between institutions and countries is possible, contributing significantly to data standardization. In addition, it is cost-effective because it is possible to utilize existing tools rather than develop new tools for the standardization of medical information [25].

Research topics using ICF were also observed during item development for a new functioning measurement tool [28,29]. Research topics that applied ICF codes to the content development of daily life guideline applications were also confirmed [30]. This confirms the application of ICF, a biopsychosocial model, to the development of tools with various contents.

The most widely used ICF area in the entire specialized area of the research paper was in the order of activity, participation, and physical function, which is similar to previous studies [11,12]. On the other hand, although there was relatively less information on environmental factors than other components, the application increased more than in previous studies [31]. All ICF domains should be applied to profile functioning. In some studies, however, specific domains were selected and applied [32,33]. Even if there are difficulties in performing the function, modification of the environment can compensate for this, so the collection of related information is considered essential for reducing the activity limitations and restrictions on the activities and participation of subjects.

In physical therapy and rehabilitation medicine, the ICF code was used more than the ICF domain. This is thought to reflect the recommendation to use a lower-level code to obtain more detailed functioning information because of the characteristics of the clinical field [34-36]. The ICF code suitable for the purpose and the level of the corresponding code should be appropriately selected.

This study had some limitations. There may be articles in clinical areas omitted because the search was conducted using the related search terms in the four databases: RISS, KISS, NDSL, and PubMed. In addition, research in other clinical areas was not included in the analysis because the subjects were papers published in journals registered with the National Research Foundation of Korea and candidate journals. Nevertheless, it is considered a meaningful approach to examine the research trends according to the expertise areas of the domestic clinical field and to find a way to activate the use of ICF based on research published within the last five years.

After reviewing ICF-related research in the domestic clinical field, the following application plan is proposed to promote the use of ICF, an international standard classification, in the clinical field.

The unification of terms is important for communication between various fields, but in domestic clinical practice, the ICF terms translated into Korean were not unified. The study reported in the Korean medicine field used the Korean Standard Classification of Functioning, Disability, and Health (KCF). This is the standard classification of the health sector established by Statistics Korea. It is based on the ICF and is a classification system that reflects the domestic situation. Classifying health and health-related information and functioning information using KCF as a unified term is believed to help communication between various specialized fields and promote reliable domestic statistical data accumulation.

For smooth communication between the clinical areas of expertise, it is important to select an appropriate ICF code for patient evaluation and use the outcome with the qualifier applied. For this, research on standardized education for ICF is required. In addition, developing a casebook using ICF that reflects the characteristics of domestic expertise areas and includes Korean culture will help enhance the understanding of ICF.

Research related to developing education or evaluation tools that map the characteristics of various subjects, such as patients, guardians, children, and health promotion program subjects, into ICF is needed. The system should be designed so that users can easily understand and conveniently access it. Research related to the development of a computer program that is easy to input, output, compare, and store functioning data using ICF is required. Furthermore, research is needed to develop a program and instructions that can accurately present the ICF code and classify the degree of function performance based on the input functioning information.

Research related to establishing a system that can share functioning-related information in various institutions, such as hospitals, welfare centers, schools, and nursing homes, is also required. It is contemplated that the sharing of such information can be used to plan and provide appropriate services to the subject. In addition, the accumulation of information can be utilized for health-related policy establishment and budgeting. Lastly, research should be conducted nationally because the above studies require collaboration among experts in various fields.

Ⅴ. Conclusion

This study examined the trends in ICF-related research conducted in the domestic clinical field over the past five years to find ways to utilize them. In physical therapy, occupational therapy, and rehabilitation medicine, ICF-related research has been conducted targeting patients and previous papers. To promote the use of ICF in the domestic clinical field, the following studies are needed: unification of ICF terminology, ICF standardized education, development of ICF use casebook, tool analysis and development using ICF, development of ICF coding program and guidelines, the establishment of a linkage system between related organs, and multidisciplinary research at the national level. 

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