Physical Therapist Management of Acute and

Chronic Low Back Pain Using the World Health

Organization's International Classification of
Functioning, Disability and Health
Sean D Rundell, Todd E Davenport and Tracey Wagner
PHYS THER. 2009; 89:82-90.
Originally published online November 13, 2008
doi: 10.2522/ptj.20080113

The online version of this article, along with updated information and services, can be
found online at: http://ptjournal.apta.org/content/89/1/82

Online-Only Material http://ptjournal.apta.org/content/suppl/2009/01/27/89.1.82

.DC1.html
Collections This article, along with others on similar topics, appears
in the following collection(s):
Case Reports
Disability Models
Injuries and Conditions: Low Back
International Classification of Functioning, Disability
and Health (ICF)
e-Letters 2 e-letter(s) have been posted to this article, which can
be accessed for free at:
http://ptjournal.apta.org/cgi/eletters/89/1/82

To submit an e-Letter on this article, click here or click on

"Submit a response" in the right-hand menu under
"Responses" in the online version of this article.
E-mail alerts Sign up here to receive free e-mail alerts

Correction A correction has been published for this article. The

correction has been appended to this PDF. The
correction is also available online at:
http://ptjournal.apta.org/content/89/3/310.full.pdf

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015

 Case Report
SD Rundell, PT, DPT, OCS, is Phys-
ical Therapist, Portland Sports
Medicine and Spine Physical Ther-
apy, 1610 SE Glenwood St, Port-
land, OR 97202 (USA). Address all
correspondence to Dr Rundell at:
sean@pdxspine.com.
TE Davenport, PT, DPT, OCS, is
Assistant Professor, Department of
Physical Therapy, Thomas J. Long
School of Pharmacy and Health
Sciences, University of the Pacific,
Stockton, California, and Clinical
Specialist, Department of Physical
Medicine and Rehabilitation, Kai-
ser Permanente Woodland Hills
Medical Center, Woodland Hills,
California.
T Wagner, PT, MPT, OCS, is Clin-
ical Specialist, Department of
Physical Medicine and Rehabilita-
tion, Kaiser Permanente Wood-
land Hills Medical Center, and
Clinical Mentor, Residency in Or-
thopaedic Physical Therapy, Kaiser
Permanente Southern California.
[Rundell SD, Davenport TE, Wag-
ner T. Physical therapist manage-
ment of acute and chronic low
back pain using the World Health
Organizations International Classi-
fication of Functioning, Disability
and Health. Phys Ther. 2009;89:
8290.]
2009 American Physical Therapy
Association
Post a Rapid Response or
find The Bottom Line:
www.ptjournal.org
82 f Physical Therapy Volume 89 Number 1
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Physical Therapist Management of
Acute and Chronic Low Back Pain
Using the World Health
Organizations International
Classification of Functioning,
Disability and Health
Sean D Rundell, Todd E Davenport, Tracey Wagner
Background and Purpose. The World Health Organizations Classification of
Functioning, Disability and Health (WHO-ICF) model was developed to describe,
classify, and measure function in health care practice and research. Recently, this
model has been promoted as a successor to the Nagi model by some authors in the
physical therapy literature. However, conceptual work in demonstrating use of the
WHO-ICF model in physical therapist management of individual patients remains
sparse. The purpose of this case report series is to demonstrate the application of the
WHO-ICF model in clinical reasoning and physical therapist management of acute and
chronic low back pain.
Case Description. Two patients, 1 with acute low back pain and 1 with chronic
low back pain, were treated pragmatically using the WHO-ICF model and other
applicable models of clinical reasoning.
Intervention. Manual therapy, exercise, and education interventions were di-
rected toward relevant body structure and function impairments, activity limitations,
and contextual factors based on their hypothesized contribution to functioning and
disability.
Outcome. Both patients demonstrated clinically significant improvements in mea-
sures of pain, disability, and psychosocial factors after 3 weeks and 10 weeks of
intervention, respectively.
Discussion. The WHO-ICF model appears to provide an effective framework for
physical therapists to better understand each persons experience with his or her
disablement and assists in prioritizing treatment selection. The explicit acknowledg-
ment of personal and environmental factors aids in addressing potential barriers. The
WHO-ICF model integrates well with other models of practice such as Sacketts
principles of evidence-based practice, the rehabilitation cycle, and Edwards and
colleagues clinical reasoning model. Future research should examine out-
comes associated with the use of the WHO-ICF model using adequately designed
clinical trials.
January 2009
 Low Back Pain and the WHO-ICF Model

L
ow back pain (LBP) is among the
most ubiquitous and expensive
health conditions affecting the
developed world.1 4 Low back pain
also is among the most common
musculoskeletal conditions treated
by physical therapists.5 As a complex
biopsychosocial phenomenon, the
application of the medical model to
describe LBP has challenged the
identification of optimal treatments.
Disability models provide useful
patient-centered schema that assist
clinicians in understanding the influ-
ences and relationships among LBP,
its hypothetical contributing factors,
and its resultant disability. Disable-
ment models such as the Nagi model
can help a clinician evaluate and pri-
oritize the components that may be
most responsive to interventions to
reduce disability,6,7 and they can be
helpful in determining needs, match-
ing interventions to health states,
and evaluating outcomes.8,9

The World Health Organizations In- Figure 1.

ternational Classification of Func-
tioning, Disability and Health
(WHO-ICF) model was developed to
simplify the process of describing,
classifying, and measuring function
and health. It provides a method
that considers biological, individual,
and social contributions that can be
used across clinical practice and re-
search. The WHO-ICF model has 2
main components (Fig. 1). The first
part is functioning and disability,
which is further divided into body
functions and structures, activities,
and participation. Body functions
and structures are assessed in terms
of change in physiological function
and anatomical structure. Activity is
the execution of a task or action,
and participation is defined as in-
volvement in life affairs. Function-
ing is the positive aspect of these
components, and disability is the
negative aspect. Each component
can be broken down into categories
relating to functioning and disability.
The second main component of the
World Health Organizations International Classification of Functioning, Disability and
Health model.
WHO-ICF model includes a classifica-
tion system to further describe envi-
ronmental and personal contextual
factors that can influence function-
ing and disability.10
The WHO-ICF model is thought to
retain certain advantages over the
Nagi model. First, the WHO-ICF
model explicitly acknowledges bi-
directional relationships among do-
mains of function and contextual
factors. In addition, the WHO-ICF
models description of contextual
factors would appear to reinforce
physical therapists consideration of
patients affective, social, and envi-
ronmental factors that contribute to
the physical therapists prognosis.
These advantages have contributed
to the WHO-ICF model being advo-
cated in the physical therapy litera-
ture11,12 as a potential successor to
the Nagi model. The WHO-ICF model
already has been applied to describe
certain chronic conditions, such as
LBP, in order to derive core sets
and brief core sets that use con-
sistent language.8,13 However, the
WHO-ICF models usefulness to clin-
ical reasoning in individual patient
cases remains unclear. The purpose
of this case report series is to dem-
onstrate the use of the WHO-ICF
framework in the management of
acute and chronic LBP.
Patient 1 (Chronic LBP)
History
The patient was a 53-year-old woman
with a chief concern of a 28-year
history of LBP. She reported an insid-
ious onset of symptoms that had pro-
gressively worsened and had be-
come constant during the last 3
years. Pain intensity, as measured

January 2009 Volume 89 Number 1 Physical Therapy f 83

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Low Back Pain and the WHO-ICF Model
with a numeric pain rating scale,14 16
was 5/10 at intake, 10/10 at worst,
and 3/10 at best. Lifting, bending for-
ward, and sitting for 15 to 20 min-
utes aggravated symptoms. The pa-
tient described the symptoms as
variable from day to day, but typi-
cally worse at the end of the day. She
estimated her sleep was interrupted
by 50% because of her LBP. Symp-
toms eased with heat, massage, and
over-the-counter ibuprofen. Associ-
ated symptoms included an intermit-
tent ache along the paraspinal mus-
culature and an intermittent ache
to throbbing pain radiating from the
lateral hips to the anterior thighs.
She also reported occasional bilateral
numbness of the entire foot at night
and upon waking. The patient re-
ported having no saddle paresthesia,
change in bowel and bladder func-
tion, or generalized weakness or
incoordination of her lower
extremities.
Other medical history included an
appendectomy, tonsillectomy, hys-
terectomy, hypertension, hypercho-
lesterolemia, and depression. Her
depressive symptoms were being
treated with bupropion hydrochlo-
ride (150 mg twice daily). Other cur-
rent medications included lisinopril
(10 mg once daily) and hydrochlo-
rothiazide (25 mg once daily) for hy-
pertension, metoclopramide (10 mg
once daily) for gastroesophageal re-
flux, and lamotrigine (200 mg once
daily) for stabilizing mood. The pa-
tients work activities included lift-
ing and carrying boxes of files and
sitting at a computer. Her hobbies
included gardening. The patients
goals were to garden and perform all
work duties with a pain level of
4/10.
Examination
At intake, the patients Oswestry
Low Back Disability Questionnaire
(ODQ)15,17,18 score was 18/50, her
Beck Depression Index (BDI)19,20
was 8/63, indicating minimal de-
84 f Physical Therapy Volume 89 Number 1
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
pressive symptoms; and her Fear-
Avoidance Belief Questionnaire
(FABQ)21,22 work subscale score
was 2/42, suggesting minimal fear-
avoidance behavior concerning work
activities. However, her FABQ physi-
cal activity subscale score was 20/24,
indicating high fear-avoidance behav-
ior concerning physical activity out-
side of work. The Lower Back Activ-
ity Confidence Scale (LoBACS)23,24
revealed scores of 49%, 90%, and
100% for the perceived ability to
function in activities of daily living
and work activities, self-regulate
symptoms, and perform therapeutic
exercises, respectively.
The patient was observed to have
decreased lumbar lordosis, posterior
pelvic tilt, and forward head in a
standing position. Decreased hip ex-
tension during terminal stance bilat-
erally and increased frontal-plane
motion of the pelvis during mid-
stance were noted during observa-
tional gait assessment. Patellar re-
flexes were 1 bilaterally, and
Achilles reflexes could not be elic-
ited. Myotomal and dermatomal
function were normal. Standing lum-
bar active range of motion (AROM)25
revealed increased left-sided pain
with flexion but normal excursion.
Extension, right side bending, and
left side bending did not reproduce
symptoms, although excursion was
decreased. Passive range of motion
(PROM) during a right straight leg
raise (SLR), as measured with bubble
inclinometry, was 52 degrees, with
reproduction of right gluteal pain,
but sensitizing using dorsiflexion
was negative. Left SLR was positive
at 60 degrees for familiar back pain,
and sensitizing with dorsiflexion was
positive.
Hip extension PROM during a
Thomas test, as measured using bub-
ble inclinometry with the knee
flexed,26 revealed right hip exten-
sion lacking 15 degrees and left hip
extension lacking 18 degrees. Man-
ual muscle tests of the hip revealed
bilateral gluteus medius muscle
strength (force-generating capacity)
was 3/5 and gluteus maximus mus-
cle strength was 3/5.27 Abdominal
performance testing, which was con-
ducted as described by Sahrmann,28
showed level 0.3 was the highest
level performed correctly, where
level 2 indicates adequate strength
and control. Hypomobility and re-
production of greater left-sided pain
than right-sided pain were noted
with posterior-anterior pressures at
L4-L5 and L5-S1.29,30
Evaluation
Based on the initial examination
data, the mediators influencing the
patients chronic LBP were catego-
rized using the WHO-ICF model
(Tab. 1). We hypothesized that hip
muscle performance and length im-
pairments observed resulted in poor
segmental stabilization and conse-
quent LBP, causing limitations in the
activities of lifting and carrying and
maintaining body positions. Difficul-
ties with these activities were hy-
pothesized to negatively affect her
participation in employment duties
and leisure activities. They also were
thought to be involved in a cycle that
promoted further impaired muscle
power functions and reduced joint
mobility.
Another important hypothesized bi-
directional relationship was between
the personal factor of her high FABQ
physical activity score and her activ-
ity limitations. We hypothesized that
fear-avoidance beliefs acted as a po-
tential barrier to her physical activi-
ties. Conversely, we thought that the
pain experienced during these activ-
ities reinforced her avoidance beliefs
concerning them. The personal fac-
tor of low self-efficacy concerning
daily living and work activities was
thought to be another factor contrib-
uting to her activity limitations. Go-
ing in the other direction, the pain
and limitation with physical activi-
January 2009
 Low Back Pain and the WHO-ICF Model

Table 1.
The World Health Organizations International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the
Evaluation of Patient 1 (Chronic Low Back Pain)a
Body Structures and Functions Activities Participation

Patients perspective Pain in back and thighs Lifting Unable to garden

Foot numbness Bending Decreased work tolerance

Sitting 20 min Interrupted sleep

Physical therapists perspective 1. Reduced muscle power functions 1. Lifting and carrying objects 1. Remunerative employment
(b730) (d430) (d850)

2. Reduced mobility of joint functions 2. Maintaining body position (d410) 2. Recreation and leisure (d920)
(b710)

3. Gait pattern function (b770)

Contextual Factors

Personal

Temperament and personality functions: fear-avoidance behavior for physical activities and perceived ability to function in activities of daily living
and work activities

Environmental

Design construction and buildings products and technology of buildings for private use (e155)
Products and technology for employment (e135)

Labor and employment services, systems, and policies (e590)

a
The physical therapists perspective includes the ranked WHO-ICF categories within each of the components. Hip muscle performance and length deficits
were ranked as the primary body structures and functions to be treated because of their degree of impairment found during the examination. They were
hypothesized to result in poor spinal segmental stabilization and consequent low back pain, which principally contributed to the patients activity limitations
of lifting and carrying and maintaining body positions and her participation restrictions in employment and leisure. The personal contextual factor of fear of
physical activity was addressed as a secondary factor that also contributed to activity limitations and participation restrictions.

ties likely reduced her perceived
ability to perform them. Her work
environment, involving low shelves
and filing cabinets, and the distance
required to transport files were envi-
ronmental factors that may have neg-
atively influenced her participation
in work duties.
Intervention
The patient was educated on her
physical therapists diagnosis, prog-
nosis, and plan of care. She was seen
for 4 visits over 10 weeks. Patient
education and graded exercise were
used to address her avoidance of
physical activity. Specifically, she
was educated during the initial visit
that pain did not signal harm, to
maintain a consistent activity pace,
and to stay as active as tolerable. This
was reinforced during discussions in
subsequent visits. Graded exercise
consisted of beginning a daily pro-
gram of walking for 15 minutes and
progressing the duration every cou-
ple days. To address decreased ab-
dominal muscle power function, she
was instructed in supine abdominal
drawing-in.28 Quarter squats without
allowing knee valgus were pre-
scribed for muscle performance im-
pairments of her hip lateral rotators
and abductors, and a hip flexor
stretch was prescribed to address
her impairment of hip extension. On
follow-up visits, interventions fo-
cused on contract-relax procedures
to the rectus femoris and iliopsoas
muscles. Abdominal bracing in a su-
pine position was progressed in in-
tensity to bracing with alternate
marching.28 Prone hip extension
AROM with knee flexion was added
to strengthen the hip extensors, and
squatting was progressed in depth
and resistance provided.
Outcome
At 10 weeks, the patient reported
that she was able to bend and carry
charts at work for a full day without
increased pain. She regularly sat at
work for 30 minutes without pain.
Her worst pain was reported as 3/10.
Her ODQ score was 6/50. Hip flex-
ion with the Thomas test was 6 de-
grees on the left and 10 degrees on
the right. Abdominal strength was
graded as level 0.4.28 The patient
canceled a follow-up appointment at
14 weeks and subsequently was con-
tacted by telephone. Final question-
naires revealed an ODQ score of
2/50, a BDI of 4/63, an FABQ work
subscale score of 0/42, and an FABQ
physical activity subscale score of
6/24. The patients LoBACS scores
were 87%, 100%, and 100% for the
functional, self-regulatory, and exer-
cise subscales, respectively. Pain in-
tensity, as measured with a numeric
pain rating scale, was 2/10 at worst.
The patient global rating of change
scale31 revealed a perception of
much improved.

January 2009 Volume 89 Number 1 Physical Therapy f 85

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Low Back Pain and the WHO-ICF Model
Patient 2 (Acute LBP)
History
The patient was a 38-year-old female
computer programmer. Her chief
concern was a 14-day history of in-
termittent right lumbar burning and
pressure. The patients symptoms
were characterized by a sudden on-
set when standing after sitting for 3
hours at her computer. She rated her
symptoms as 8/10 at worst, 0/10 at
best, and 5/10 at the time of her
examination. Aggravating activities
included sitting 2 hours or longer,
sleeping supine for 1 hour or longer,
jogging longer than 45 minutes, and
weight bearing on her right lower
extremity. She usually awakened
without pain in the morning and ex-
perienced her symptoms after sitting
at work. Her symptoms continued to
worsen throughout the day. She also
reported a secondary concern of
burning right lateral leg pain that
she experienced intermittently dur-
ing the last year. This pain began
insidiously 1 year previously, concur-
rently with multiple brief episodes
of LBP. Her episodic LBP resolved,
but the leg pain remained aggravated
with jogging, driving or prolonged
sitting.
At the time of intake, she reported
that her leg pain increased as her
right LBP increased. Her symptoms
eased with changing positions from
sitting or supine, using her elliptical
machine, and using her abdominal
exercise equipment. She slept with-
out disturbance in a side-lying posi-
tion. The patient stated that her pain
intensity had diminished since initial
onset. She reported having no numb-
ness or paresthesias in her lower ex-
tremities, change in bowel or blad-
der function, saddle paresthesia, or
weakness or incoordination in the
lower extremities. Significant medi-
cal history included anxiety disorder
and depression. Medications in-
cluded ibuprofen (600 mg 3 times
daily, as needed) for pain and inflam-
mation, nortriptyline (600 mg 3
86 f Physical Therapy Volume 89 Number 1
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
times daily) for depressive symp-
toms, methylprednisolone (4 mg
once daily) for inflammation, fexofe-
nadine (60 mg once daily) for aller-
gies, and norethindrone (35 mg once
daily) for contraception. Her work
activities were sitting at a computer
8 hours a day, and she had a 1-hour
commute to and from work. Her ex-
ercise program included jogging, us-
ing the elliptical machine, and ab-
dominal curls with a floor-exercise
apparatus. The patients goal was to
sit 5 hours at work unlimited by
pain.
Examination
The patients initial Roland-Morris
Disability Questionnaire (RMQ)15,18,32
score was 5/24. The RMQ was se-
lected prior to the case due to its
sensitivity to change in people with
acute LBP.18 The patients FABQ
scores were 18/42 for the work
subscale and 9/24 for the physical
activity subscale, indicating low
fear-avoidance beliefs. Her LoBACS
scores were 86%, 100%, and 90% for
the function, self-regulatory, and ex-
ercise subscales, respectively.
The patient displayed decreased tho-
racic kyphosis, increased lumbar lor-
dosis, and greater prominence of the
right lumbar paraspinal musculature
with visual postural assessment. Ini-
tial pain in a standing position was
1/10 located at the right lumbar
spine and lateral leg. During right
single-leg stance, the patient had in-
creased lumbar pain and increased
pelvic drop with trunk rotation. Left
single-leg stance was pain-free with a
level pelvis. Myotomal lower-quarter
strength screening revealed the
L1-L5 innervated muscles were
graded as 5/5 and equal bilaterally.
The S1 myotome testing demon-
strated 8 unilateral heel-raises on
the left and 6 unilateral heel-raises
on the right, with right heel-raise
performance limited by leg pain
rather than weakness. Dermatomal
light touch was normal. Patellar and
Achilles tendon deep tendon reflex
tests were 2 bilaterally. Lumbar
AROM revealed flexion was normal
and status quo. Extension was lim-
ited with increased right lumbar pain
at end-range. Left side bending was
limited, and her right lumbar pain
was worse at end-range. Right side
bending was normal and status quo.
Prone hip medial (internal) rotation
PROM was 56 degrees on the left and
54 degrees on the right, and lateral
(external) rotation was 46 degrees
on the left and 48 degrees on the
right. Straight leg raise was negative
with 96 degrees of PROM on the left.
Straight leg raise on the right was
positive for reproduction of LBP at
88 degrees, and it was unchanged
with dorsiflexion sensitizers. Tender-
ness and restrictions were noted
with palpation of the right lumbar
paraspinals. The right L5-S1 segment
was hypomobile and reproduced her
lumbar pain. The left L5-S1 segment
was hypomobile and pain-free. The
L12 through L4 5 segments had
normal mobility, which was painful
on the right and pain-free on the left.
Evaluation
Based on the initial examination
data, the mediators influencing the
patients acute LBP were categorized
and ranked above using the ICF
model (Tab. 2). The patient met 4 of
the 5 criteria that predict success
with manipulation in patients with
LBP, and she did not have any signs
of nerve root compression. Research
suggesting she had a 92% chance of a
successful outcome with lumbopel-
vic manipulation prioritized her re-
duced mobility of joint functions as
the primary body function limita-
tion.33 We hypothesized that the re-
duced mobility of joint function at
L5S1 on the right and the resulting
sensations of pain were contributing
to her limitations with maintaining
body positions and movement. Her
limited movement and sensation of
pain contributed to her restrictions
in regular recreation activities. The
January 2009
 Low Back Pain and the WHO-ICF Model

Table 2.
The World Health Organizations International Classification of Functioning, Disability and Health (WHO-ICF) Model Applied to the
Evaluation of Patient 2 (Acute Low Back Pain)a
Body Structures and Functions Activities Participation

Patients perspective Pain in back Sitting 2 h Limited exercise program

Pain in leg Lying supine 1 h Interruption of work

Jogging 45 min

Physical therapists perspective 1. Reduced mobility of joint functions 1. Maintaining body position 1. Recreation and leisure (d920)
(b710) (d410)

2. Sensation of pain (b280) 2. Moving around (b455) 2. Remunerative employment (d850)

3. Control of voluntary movement

functions (b760)

4. Neural tissue provocation

Contextual Factors

Personal

No personal factors were deemed to be barriers as measured by the selected questionnaires

Facilitators: activity level and continuation of exercise

Environmental
Health professionals (e355)

Products and technology for employment (e135)

Labor and employment services, systems, and policies (e590)

Transportation services, systems, and policies (e590)

a
Mobility of joint functions and sensation of pain were ranked as the primary body functions because the patient met the clinical prediction rule for
manipulation. It was hypothesized that these impaired body functions were contributing to her limitations with maintaining body positions and movement,
thereby restricting her participation in regular recreational activities. Neural provocation was prioritized next because the slump test reproduced her leg
pain. Control of voluntary movement functions was considered to reduce the likelihood of reoccurring episodes of low back pain.

contextual factor of the health care
professionals awareness and appli-
cation of research evidence was
thought to positively mediate her re-
habilitation. A significant bidirec-
tional relationship in this case was
between the requirement of sitting
at a computer for 8 hours for em-
ployment and her sensation of pain.
Pain limited her ability to maintain
this body position, but the duration
of sitting required for her work led
to increased pain intensity. The pa-
tient was given an excellent progno-
sis due to the strong research evi-
dence for her improvement with
manipulation.
Intervention
The patient received 3 treatment ses-
sions over 23 days. She was educated
on her physical therapists diagnosis,
prognosis, and plan of care. The ini-
tial intervention involved a left side-
lying manipulation technique di-
rected at L5S1 on the right to
improve mobility of joint function
and reduce sensation of pain.34 Sub-
sequently, the patient was instructed
in a home exercise program of left
side lying with right trunk rotation
AROM. She was educated on sitting
posture and ergonomics for com-
puter use to address the potential
environmental barrier of prolonged
sitting at a computer for work. Dur-
ing the second visit, the side-lying
manipulation was repeated. Further
examination revealed a negative SLR,
but slump testing was positive for
LBP and increased right leg pain. The
patient was instructed in a self-
administered AROM exercise in the
test position to address the associ-
ated reduced nerve mobility and sen-
sation of pain. She was instructed to
take a standing break from sitting
every hour at work to minimize the
environmental barrier of sitting for
work. During visit 2, testing of prone
hip extension with knee extended
on the right revealed anterior pelvic
rotation and right ilium anterior ro-
tation in the transverse plane, indi-
cating a lack of lumbopelvic neuro-
muscular control. This was the only
remaining impaired body function at
visit 3. The patient was prescribed
prone hip extension stabilization ex-
ercise to address this impairment.
Outcome
Immediate improvement was dem-
onstrated after the initial manipula-
tion, with 0/10 lumbar and leg pain
in standing, no pain with lumbar ex-
tension AROM, decreased pain with
left side-bending AROM, and no pain
with right single-leg stance. At the
second visit, her right LBP and leg
pain were less intense (ie, 2/10 at
worst). Extension created right lum-

January 2009 Volume 89 Number 1 Physical Therapy f 87

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Low Back Pain and the WHO-ICF Model
bar pain at end-range, and right
L5S1 accessory motion was still
painful and hypomobile. She was
able to sit 5 hours at work without
LBP, and her RMQ score was 1/24.
During the final visit, the patient re-
ported no pain since the day of the
last treatment. She was working a
full day and returned to jogging with-
out pain. Her final RMQ score was
0/24. Her LoBACS scores were 91%,
100%, and 100% for the function,
self-regulatory, and exercise sub-
scales, respectively. Her FABQ
scores were 5/42 for the work sub-
scale and 4/24 for the physical activ-
ity subscale. Re-examination demon-
strated normal lumbar AROM,
normal and pain-free accessory mo-
tion testing, and a negative slump
test. The patient was discharged
from physical therapy with all goals
met.
Discussion
The WHO-ICF model is character-
ized by a bidirectional flow of infor-
mation rather than hierarchical orga-
nization of its domains. This was
demonstrated with several hypothe-
sized bidirectional relationships in
the 2 cases. The WHO-ICF model ap-
pears to provide an effective frame-
work for physical therapists to better
understand each persons experi-
ence with his or her disablement and
assist in prioritizing treatment selec-
tion. It is notable that the health con-
dition identified in this case series
was LBP, which is a symptom-based
condition rather than a specific,
tissue-based pathology.35 The WHO-
ICF model assisted in identifying
body structure and function deficits
and activity limitations. Interven-
tions directed at these impairments,
contextual factors, and limitations
addressed the health condition and
appeared to affect activity and par-
ticipation. For example, the hip
muscle performance and length def-
icits observed in the patient with
chronic LBP were hypothesized to
result in poor segmental stabilization
88 f Physical Therapy Volume 89 Number 1
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
and consequent LBP. The WHO-ICF
model may predict the potential
success of physical therapy inter-
ventions for other symptom-based
health conditions in which a spe-
cific, tissue-based pathology is
unclear.
Patients in this case report series
benefited from the WHO-ICF mod-
els explicit acknowledgment of per-
sonal and environmental factors as
important contributors to disable-
ment through their interaction with
the physical domains. For the patient
with chronic LBP, a belief related to
avoidance of physical activity was a
negative personal factor. Recogniz-
ing this negative personal factor al-
lowed the therapist to direct specific
educational interventions designed
to reduce her fear-avoidance behav-
ior and secondarily her participation
restrictions. Environmental factors
also played a large role in both cases.
In the patient with chronic LBP, the
structural setup of her workspace,
the use of a computer for work, and
the requirements that she transport
files contributed to her participation
at work. The requirement that the
woman with acute LBP sit and work
at a computer 8 hours a day for her
job greatly played a part in her
disability.
Existing clinical reasoning models
were used concurrently with the or-
ganization of function provided by
the WHO-ICF model (Fig. 2). For ex-
ample, Edwards and colleagues clin-
ical reasoning model36 was used to
organize the appropriate perfor-
mance of the functions of the phys-
ical therapist. A hypothesis was de-
veloped from history and physical
examination data, the therapists
knowledge, and the patients experi-
ence. After the evaluation, the ther-
apist selected the best possible inter-
ventions based on research, clinical
experience, and patient preference
that matched the previously selected
components. Reassessment oc-
curred by monitoring the effective-
ness of the interventions using vari-
ous outcome assessments from the
examination to measure change in
activities and participation. Ques-
tionnaires with acceptable psycho-
metrics allowed accurate measure-
ment of patient perceptions in order
to evaluate and modify the hypothe-
ses developed within the WHO-ICF
framework as the rehabilitation cy-
cles continued. In addition to the
concept of the rehabilitation cycle,
evidence-based practice principles
were used to identify the best possi-
ble examination, evaluation, and in-
tervention strategies.37 Classifying
acute LBP into treatment-based cate-
gories based on clinical presentation
has been associated with superior
outcomes compared with non-
matched treatments.33,38 Clearly, al-
though the WHO-ICF provides a
powerful new tool for physical ther-
apists, existing clinical reasoning
models may be expected to retain
complementary roles in the clinical
reasoning process by physical
therapists.
This case report provided 2 exam-
ples of the application of the WHO-
ICF model in patients with LBP. It
provides preliminary evidence for
the clinical utility of the bidirectional
relationships among the WHO-ICF
models domains, explicit acknowl-
edgment of personal and environ-
mental factors that affect disable-
ment, and potential complementary
clinical reasoning models. Future re-
search is necessary to apply the
WHO-ICF model to other body re-
gions and health conditions common
in physical therapist practice. This
research should establish the clinical
effectiveness of its application and
derive core sets that may be useful
for optimal education, research, and
reimbursement.
Dr Rundell and Dr Davenport provided con-
cept/idea/project design, writing, and data
January 2009
 Low Back Pain and the WHO-ICF Model

Figure 2.
Integrated model of physical therapist clinical reasoning incorporating the World Health Organizations International Classification of
Functioning, Disability and Health (WHO-ICF) model, with important concepts from Sacketts principles of evidence-based practice,37
the rehabilitation cycle, and Edwards and colleagues clinical reasoning model of physical therapists.36

analysis. Ms Wagner assisted in the project
design. Dr Rundell provided data collection,
project management, and patients. Dr Dav-
enport and Ms Wagner provided consulta-
tion (including review of manuscript before
submission).
Dr Rundell completed this case report series
in partial fulfillment of the requirements of
the Kaiser Permanente Southern California
Orthopaedic Physical Therapy Residency.
The authors thank Joe Godges, PT, DPT,
OCS, for his insightful comments regarding
an early version of the manuscript. The au-
thors also gratefully recognize Kris M Keller,
PT, Department Administrator, and Justin W
Hamilton, PT, MPT, OCS, for their adminis-
trative support of this project. The authors
affirm that they have no financial affiliation
or involvement with any commercial organi-
zation that has a direct financial interest in
any matter included in the article.
This article was received April 16, 2008, and
was accepted October 3, 2008.
DOI: 10.2522/ptj.20080113

January 2009 Volume 89 Number 1 Physical Therapy f 89

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
Low Back Pain and the WHO-ICF Model
References
1 Deyo RA, Mirza SK, Martin BI. Back pain
prevalence and visit rates: estimates from
US national surveys, 2002. Spine. 2006;31:
2724 2727.
2 Hashemi L, Webster BS, Clancy EA, Volinn
E. Length of disability and cost of workers
compensation low back pain claims. J Oc-
cup Environ Med. 1997;39:937945.
3 Loney PL, Stratford PW. The prevalence of
low back pain in adults: a methodological
review of the literature. Phys Ther. 1999;
79:384 396.
4 Walker BF, Muller R, Grant WD. Low back
pain in Australian adults: prevalence and
associated disability. J Manipulative
Physiol Ther. 2004;27:238 244.
5 Jette AM, Smith K, Haley SM, Davis KD.
Physical therapy episodes of care for pa-
tients with low back pain. Phys Ther.
1994;74:101110; discussion 110 105.
6 Jette AM, Assmann SF, Rooks D, et al. In-
terrelationships among disablement con-
cepts. J Gerontol A Biol Sci Med Sci.
1998;53:M395M404.
7 Jette AM, Keysor JJ. Disability models: im-
plications for arthritis exercise and physi-
cal activity interventions. Arthritis Rheum.
2003;49:114 120.
8 Stucki G, Cieza A, Ewert T, et al. Applica-
tion of the International Classification of
Functioning, Disability and Health (ICF) in
clinical practice. Disabil Rehabil. 2002;
24:281282.
9 Stucki G, Ewert T, Cieza A. Value and ap-
plication of the ICF in rehabilitation med-
icine. Disabil Rehabil. 2003;25:628 634.
10 International Classification of Function-
ing, Disability and Health: ICF. Geneva,
Switzerland: World Health Organization;
2001.
11 Irrgang JJ, Godges J. Use of the Interna-
tional Classification of Functioning and
Disability to develop evidence-based
practice guidelines for treatment of com-
mon musculoskeletal conditions. Ortho-
paedic Physical Therapy Practice. 2006;
18(4):24 25.
12 Jette AM. The changing language of dis-
ablement. Phys Ther. 2005;85:118 119.
13 Cieza A, Stucki G, Weigl M, et al. ICF Core
Sets for low back pain. J Rehabil Med.
2004(44 suppl):69 74.
14 Childs JD, Piva SR, Fritz JM. Responsive-
ness of the numeric pain rating scale in
patients with low back pain. Spine.
2005;30:13311334.
90 f Physical Therapy Volume 89 Number 1
Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015
15 Grotle M, Brox JI, Vollestad NK. Concur-
rent comparison of responsiveness in pain
and functional status measurements used
for patients with low back pain. Spine.
2004;29:E492E501.
16 Von Korff M, Jensen MP, Karoly P. Assess-
ing global pain severity by self-report in
clinical and health services research.
Spine. 2000;25:3140 3151.
17 Fairbank JC, Couper J, Davies JB, OBrien
JP. The Oswestry low back pain disabil-
ity questionnaire. Physiotherapy. 1980;
66:271273.
18 Lauridsen HH, Hartvigsen J, Manniche C,
et al. Responsiveness and minimal clini-
cally important difference for pain and
disability instruments in low back pain
patients. BMC Musculoskelet Disord.
2006;7:82.
19 Beck AT, Steer RA, Brown GK. Beck De-
pression Inventory II Manual. San Anto-
nio, TX: The Psychological Corporation;
1996.
20 Hiroe T, Kojima M, Yamamoto I, et al. Gra-
dations of clinical severity and sensitivity
to change assessed with the Beck De-
pression Inventory-II in Japanese pa-
tients with depression. Psychiatry Res.
2005;135:229 235.
21 Swinkels-Meewisse EJ, Swinkels RA, Ver-
beek AL, et al. Psychometric properties of
the Tampa Scale for Kinesiophobia and
the Fear-Avoidance Beliefs Questionnaire
in acute low back pain. Man Ther.
2003;8:29 36.
22 Waddell G, Newton M, Henderson I, et al.
A Fear-Avoidance Beliefs Questionnaire
(FABQ) and the role of fear-avoidance be-
liefs in chronic low back pain and disabil-
ity. Pain. 1993;52:157168.
23 Davenport TE, Cleland JA, Lewthwaite R,
et al. Responsiveness of the Low Back Ac-
tivity Confidence Scale in a subgroup of
patients with low back pain: preliminary
analyses. Paper presented at: Combined
Sections Meeting of the American Physical
Therapy Association; February 6 9, 2008;
Nashville, TN.
24 Yamada KA, Lewthwaite R, Popovich JM,
et al. The Low Back Activity Confidence
Scale (LoBACS): development and prelim-
inary reliability and validity. Paper pre-
sented at: Combined Sections Meeting of
the American Physical Therapy Associa-
tion; February 14 18, 2007; Boston, MA.
25 Waddell G, Somerville D, Henderson I,
Newton M. Objective clinical evaluation of
physical impairment in chronic low back
pain. Spine. 1992;17:617 628.
26 Van Dillen LR, McDonnell MK, Fleming
DA, Sahrmann SA. Effect of knee and hip
position on hip extension range of motion
in individuals with and without low back
pain. J Orthop Sports Phys Ther. 2000;30:
307316.
27 Kendall FP, McCreary EK, Provance PG,
et al. Muscles: Testing and Function. 5th
ed. Baltimore, MD: Lippincott Williams &
Wilkins; 2007.
28 Sahrmann SA. Diagnosis and Treatment
of Movement Impairment Syndromes. St
Louis, MO: Mosby; 2001.
29 Maher CG, Adams R. Reliability of pain and
stiffness assessments in clinical manual
lumbar spine examination. Phys Ther.
1994;74:801 809; discussion 809 811.
30 Maher CG, Latimer J, Adams R. An inves-
tigation of the reliability and validity of
posteroanterior spinal stiffness judgments
made using a reference-based protocol.
Phys Ther. 1998;78:829 837.
31 Davidson M, Keating JL. A comparison of
five low back disability questionnaires: re-
liability and responsiveness. Phys Ther.
2002;82:8 24.
32 Roland M, Morris R. A study of the natural
history of back pain, part I: development
of a reliable and sensitive measure of dis-
ability in low-back pain. Spine. 1983;
8:141144.
33 Childs JD, Fritz JM, Flynn TW, et al. A clin-
ical prediction rule to identify patients
with low back pain most likely to benefit
from spinal manipulation: a validation
study. Ann Intern Med. 2004;141:
920 928.
34 Gibbons P, Tehan P. Manipulation of the
Spine, Thorax and Pelvis: An Osteopathic
Perspective. 2nd ed. Chatswood, NSW,
Australia: Churchill Livingstone; 2005.
35 Davenport TE, Watts HG, Kulig K, Resnik
C. Current status and correlates of physi-
cians referral diagnoses for physical ther-
apy. J Orthop Sports Phys Ther. 2005;35:
572579.
36 Edwards I, Jones M, Carr J, et al. Clinical
reasoning strategies in physical therapy.
Phys Ther. 2004;84:312330; discussion
331315.
37 Sackett D, Straus S, Richardson W, et al.
Evidence-Based Medicine: How to Prac-
tice and Teach EBM. 2nd ed. Edinburgh,
Scotland: Churchill Livingstone; 2000.
38 Fritz JM, George S. The use of a classifica-
tion approach to identify subgroups of pa-
tients with acute low back pain: interrater
reliability and short-term treatment out-
comes. Spine. 2000;25:106 114.
January 2009
 Physical Therapist Management of Acute and
Chronic Low Back Pain Using the World Health
Organization's International Classification of
Functioning, Disability and Health
Sean D Rundell, Todd E Davenport and Tracey Wagner
PHYS THER. 2009; 89:82-90.
Originally published online November 13, 2008
doi: 10.2522/ptj.20080113

References This article cites 29 articles, 7 of which you can access

for free at:
http://ptjournal.apta.org/content/89/1/82#BIBL
Cited by This article has been cited by 5 HighWire-hosted articles:

http://ptjournal.apta.org/content/89/1/82#otherarticles
Subscription http://ptjournal.apta.org/subscriptions/
Information
Permissions and Reprints http://ptjournal.apta.org/site/misc/terms.xhtml
Information for Authors http://ptjournal.apta.org/site/misc/ifora.xhtml

Downloaded from http://ptjournal.apta.org/ by guest on January 22, 2015

Letters to the Editor

4 International Classification of Function-
ing, Disability and Health: ICF. Geneva,
Switzerland: World Health Organization;
2001.
5 Cieza A, Stucki G, Weigl M, et al. ICF core
sets for low back pain. J Rehabil Med.
2004(44 suppl);6974.
6 International Classification of Diseases
(ICD-10). Available at: http://www.who.
int/classifications/icd/en/.
7 Irrgang JJ, Godges J. Use of the Interna-
tional Classification of Functioning and
Disability to develop evidence-based prac-
tice guidelines for treatment of common
musculoskeletal conditions. Orthopaedic
Physical Therapy Practice. 2006;18(4):
2425.
8 McPoil TG, Martin RL, Cornwall MW, et al.
Heel pain-plantar fasciitis: clinical prac-
tice guidelines linked to the International
Classification of Function, Disability, and
Health from the Orthopaedic Section of
the American Physical Therapy Associa-
tion. J Orthop Sports Phys Ther. 2008;38:
A1A18.
9 Childs JD, Cleland JA, Elliott JM, et al. Neck
pain: clinical practice guidelines linked
to the International Classification of
Functioning, Disability and Health from
the Orthopaedic Section of the American
Physical Therapy Association. J Orthop
Sports Phys Ther. 2008;38:A1A34.

[DOI: 10.2522/ptj.2009.89.3.309]

Correction
Rundell SD, Davenport TE, Wagner T. Physical therapist management of acute and chronic
low back pain... Phys Ther. 2009;89:8290.
The bidirectional arrow between Activity and Contextual Factors was omitted in Figure 1: World Health
Organizations International Classification of Functioning, Disability and Health model. The corrected figure
appears below. The Journal regrets the error.

HEALTH
CONDITION

ACTIVITY

Contextual
Factors:
Environment
& Personal

BODY FUNCTION
PARTICIPATION
AND STRUCTURE

Figure 1.
World Health Organizations International Classification of Functioning, Disability and Health model.

[DOI: 10.2522/ptj.20080113.cx]

310 Physical Therapy Volume 89 Number 3 March 2009