93 ASSESMENT, ASSISTIVE DEVICES & PROGRAMS - Service Delivery Model II

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93.3 - An evaluation of 20 year WHO-ICIDH and ICF-based activities by Visio

Looijestijn P.
1


1
Royal Visio, National Foundation for the Visually Impaired and Blind, Research & Development, Haren, Netherlands

In 1980 the WHO published the International Classification of Impairments, Disabilities and Handicaps (ICIDH) for classification of the result
of diseases and disorders. In 1993 a revision process was started, which resulted in the publication of the International Classification
of Functioning, disability and health (ICF) in 2001. According to the ICF model, rehabilitation of people with visual impairments requires insight
into the relations between visual diseases and disorders, intact and impaired visual function, visual abilities and disabilities, activities,
participation and the environmental factors. Based on that insight the focus of the rehabilitation process can shift from medical causes to
optimal participation in daily life.
In the last 20 years Royal Visio, National Foundation for the Visually Impaired and Blind in the Netherlands, has worked on the
practical implementation of the ICF model in the field of rehabilitation of visually impaired people. During this period, several modifications
and additions to the ICF model itself and the adaptation of the rehabilitation methods used in Visio were made. First, classifications of
visual impairments needed to be specified and added to the ICF model. Second, the focus of rehabilitation needed to be described in terms
of practical participation goals of the patient. Third, diagnostic methods and instruments were developed to assess low and high visual
functions, vision related activities and quality of life.
Scientific foundations for the modification and adaptation of the ICF model were provided by research projects and dissertations in
cooperation with the universities of Groningen, Utrecht and Amsterdam. Since 1993 Visio has published about these developments, for
instance on the Vision conferences.
This has resulted in a new working definition of low vision in our organisation and for eligibility for services for people with visual disabilities in
the Netherlands. These are not only based on medical cause, acuity and visual field, but also on the degree of visual disabilities and
participation problems. As a result, people with cerebral visual dysfunctions as well as people with ocular visual dysfunctions have access
to rehabilitation.

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Proceedings of the 9
th
International Conference on Low Vision,
Vision 2008, Montreal, Quebec, Canada
July 7 11, 2008



An Evaluation of 20 Years WHO-ICIDH and ICF-based activities
by Royal Visio

Paul Looijestijn, PhD
*


Royal Visio, National Foundation for the Visually Impaired and Blind
Department of Research & Development, Haren, the Netherlands


Abstract. In rehabilitation centres for visually impaired and blind people the need for a common, conceptual framework was
felt by those in various disciplines working there. Based on the classifications of the WHO (ICIDH and ICF) Visio
developed in the last 20 years an interdisciplinary model for the rehabilitation to an optimal participation of visually
impaired and blind people (IRM). A method for combining professional judgements with judgments of the client, a new
working definition of low vision, instruments for assessment and observation are developed under the umbrella term Visual
Profile. The visual profile makes it possible to gain insight into the clients visual problems from all perspectives: disease,
disorder, body function and structure, activities, participation, environmental factors, all of which aids in drawing up an
interdisciplinary rehabilitation plan. As a result, people with cerebral visual dysfunctions as well as people with ocular visual
dysfunctions have access to rehabilitation.

Keywords: WHO; ICIDH; ICF; participation; www.visualprofile.info


1. WHO: ICIDH & ICF

In 1980 the WHO published the International Classification of Impairments, Disabilities and Handicaps
(ICIDH) for classification of the result of diseases and disorders [33]. In 1993 a revision process was started
which resulted in the publication of the International Classification of Functioning, disability and health (ICF) in
2001 (see figure 1) [34]. In 2007 the WHO published the children and youth version (ICF-CY) [35].


Health Condition Health Condition
( (disorder/disease disorder/disease) )
Interaction of Concepts Interaction of Concepts
ICF 2001 ICF 2001
Environmental Environmental
Factors Factors
Personal Personal
Factors Factors
Body Body
function&structure function&structure
(Impairment (Impairment) )
Activities Activities
(Limitation) (Limitation)
Participation Participation
(Restriction) (Restriction)
















Fig. 1. The WHO-ICF model of functioning and disability: Interactions between the components of ICF.

According to the ICF model, rehabilitation of people with visual impairments requires insight into the
relations between visual diseases and disorders, intact and impaired visual function, visual abilities and

* Paul Looijestijn : paullooijestijn@visio.org Visio Noord Nederland, Postbus 144, 9750 AC Haren, the Netherlands.
disabilities, activities, participation and the environmental factors. Based on that insight the focus of the
rehabilitation process can shift from medical causes to optimal participation in daily life.

2. ICIDH and ICF-based activities Visio

In the last 20 years Royal Visio, National Foundation for the Visually Impaired and Blind in the Netherlands,
has worked on the practical implementation of the ICIDH and later the ICF model in the field of rehabilitation
of visually impaired and blind people. During this period, several modifications and additions to the ICF model
itself and the adaptation of the rehabilitation methods used in Visio were made. These developments in our
organisation are related to national and international developments elsewhere [30;3].

2.1 Classification of visual impairments

First, classifications of visual impairments needed to be specified, added to the ICF model as well as
rehabilitation services [29; 6; 12]. The anatomical structures of eyes, ocular muscles, nerves and tracts and those
parts of the brain which are involved in visual processing (dorsal and ventral stream) are important for ocular
and/or cerebral diseases or disorders of the visual system (see figure 2: part 4a and 4b). Visual impairments can
be found in two types of lower visual functions: the oculomotor and the visual sensory functions (acuity, field,
contrast, colour, light adaptation, glare etc.). But also in two types of higher visual functions: the visual-
perceptual-cognitive (visual attention, visual spatial relationship and object recognition etc.) and the visual
motor functions (eye-hand, eye-foot, eye-body) (see figure 2: part 3). In our opinion a distinction must be made
between the visual activities and self-sufficiency of activities in all life areas (see figure 2: part 2). Vision can be
an element in every activity in every life area.
This ICF-based approach to low vision is as an element included in the whole process of rehabilitation
[32;8;7]. This process of rehabilitation includes so-called moments of convergence (interdisciplinary
consultation, common language) and moments of divergence (every care provider works with and for the client
at specific goals using their specific methods of assessments and treatment of there own discipline).


4.a Ophthalmological and/or neurologi cal disease/disorder
of the visual system : D
Eyes, ocular muscles, nerves/tracts, brai n
4.b Anatomical structures
of the visual system: s
3. And/or
Lower visual functions: b1
Oculomotor
Visual sensory
And/or:
Higher visual functions: b2
Visual perceptual-cognitive
Visual motor
2. Activities in
all life areas:
a 1
Visual activities
a 2
Self-sufficiency
1. Participation in
all life areas:
p 1
5.a Environmental factors: e 5.b Personal factors
=visual related and other variables =visual variables

















Fig. 2. Selection, modification and addition of the ICF model to the basic elements of the Visual Profile.

2.2 Determining the focus of rehabilitation

Second, the focus of rehabilitation needed to be described in terms of daily life and practical participation
goals of the client. For this the method of a visual profile is developed to gain insight into the relationships
between the elements of figure 2 where there are 6 parts in the assessment segment of the process of
rehabilitation [15;16;17;18;21]: A) collect and order data in the basic elements of the Visual Profile B) translate
and understand all this data C) combine all the data and deduce hypotheses D) check those hypotheses E)
explain the clients needs and F) determine goals and actions. In part E and F the answers on 8 questions leads to
a rehabilitation diagnosis. The first 5 questions (part E) correspond with the 5 parts (shown in figure 2):

1. Are there restrictions or problems in participation and can we expect them?
2. Is there a relation with limitations in self-sufficiency and visual activities?
3. Is there a relation with visual impairments?
4. Is there a relation with diseases and disorders of the visual system?
5. In which way is there a relation with environmental and personal factors?

The other three questions involved in part F are:

6. Is this a treatment for rehabilitation of visually impaired people or for other services?
7. What are the priorities in the participation needs of the client and in which area(s) of daily life?
8. Which actions in each which part in figure 2 can contribute to optimal participation of the client?

2.3 Development of assessment methods and instruments to assess visual function

Third, assessments and instruments were developed to assess visual functions, vision related activities and
participation which correspond to the main ICF-classifications of functioning. In 1988 Aart Kooijman, Gerjan
van der Wildt a.o. started in the rehabilitation centres of Visio with the assessment of lower visual functions
[10], in 1989 this author and Anja van der Wege started the assessment of higher visual functions (part 3 in
figure 2) as well as ocular visual impairment [18;22] and cerebral visual impairment [20;28], with a
rehabilitation program for parents (figure 2: parts 1, 2 and 3) [13]. In 1994 light adaptation in daily life (figure
2: part 5.a) [4] and observation of visual activities (figure 2: part 2) [14] were included. Included in 1995 were
assimilation in and adaptation of the Bayley scales of infant development [26;27;31], in which the observation
list Visual Profile (figure 2: part 2.a 1) has been an example for other observation lists [5]. Finally, in 2004 a
standardized interview of visual activities, self-sufficiency and participation to collect the judgments of the
informant (figure 2: parts 1 and 2 for the person with visual impairments and part 5.a for other informants) were
added [1;2;18;21].
Scientific foundations for the modification and adaptation of the ICF model were provided by research
projects and dissertations in cooperation with the universities of Groningen, Utrecht and Amsterdam[4;18;11].
The classification, methods and instruments are part of the in-service training in our organisation since 1993 and
the others in the Netherlands and Flanders [15;16;17]
Since Vision 1993 in Groningen, Visio has published about these developments, for instance on the Vision
conferences [32;29;6;13;9;22;23;24;25]. This has resulted in a new working definition of low vision in our
organisation and for eligibility for services for people with visual disabilities in the Netherlands [14;18;19]. A
person with low vision experienced limitations (disabilities) in visual activities as a result of measured visual
impairments (4 groups of functions), which can result in participation problems. These approaches are based on
the main ICF-classifications of functioning: body function and structure, activities, and participation. It is not
only based on medical causes, acuity and visual field, but also on the degree of visual (dis)abilities and
participation possibilities as well as problems. As a result, people with cerebral visual dysfunctions as well as
people with ocular visual dysfunctions have access to rehabilitation, assessment when the limitations in visual
activities can be the result of visual impairments, and also for treatment when the assessments of visual
functions in all 4 groups (if necessary) confirm the visual impairment(s).

3. New parts

The ICF-based developments in our organisation are still going on. In cooperation with the other Dutch
organisations for services to visually impaired and blind people, Sensis and Bartimus, and with a grant of the Dutch
foundation ZonMw (InZicht programme), we are building a website with a forum for a worldwide exchange of
information about ICF-based contributions to the rehabilitation of people with visual impairments
(www.visualprofile.info see abstract 469). We have taken the initiative for an ICF advisory-board in our new
organisation: Visio-Sensis-de Brink groep. In cooperation with the University of Groningen we are planning
further research.

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