---

ICF Facilitators & Barriers

---

ICF Framework Overview

• Body Functions & Structures (impairments)
• Activities (limitations)
• Participation (restrictions)
• Environmental Factors (facilitators ✅ / barriers ❌)
• Personal Factors (facilitators ✅ / barriers ❌)

---

BODY FUNCTIONS & STRUCTURES

Impairments Present

---

ACTIVITIES & PARTICIPATION

Activity Limitations

Participation Restrictions

---

ENVIRONMENTAL FACTORS

✅ Facilitators (Environmental)

❌ Barriers (Environmental)

---

PERSONAL FACTORS

✅ Facilitators (Personal)

❌ Barriers (Personal)

---

SUMMARY TABLE

---

Clinical Implications for Rehabilitation

1. Early physiotherapy: Passive → active ROM for knee; bed exercises to counter ICU deconditioning
2. Glycemic control: Tight monitoring to facilitate tissue repair and reduce neuropathy progression
3. Pain management: Balanced analgesia (avoid NSAIDs due to renal risk in DM) to enable rehab participation
4. Fall prevention: Non-slip surfaces, knee orthosis, assistive device training
5. Psychological support: Screen for PICS, ICU-acquired depression; involve family
6. Discharge planning: Home modifications, outpatient physiotherapy, diabetic foot care, OA management

---

Reference: ICF framework — World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva: WHO, 2001. Referenced in: Kaplan & Sadock's Comprehensive Textbook of Psychiatry; Murray & Nadel's Textbook of Respiratory Medicine.

---

ICF Facilitators — "What To Do" for Each Impairment

---

1. Impaired Glucose Regulation (b540)

• Monitor capillary blood glucose every 4–6 hours; maintain target 140–180 mg/dL in ICU
• Initiate insulin infusion protocol if persistent hyperglycemia
• Coordinate with dietitian for carbohydrate-controlled enteral/parenteral nutrition
• Avoid dextrose-containing IV fluids unless hypoglycemia present
• Involve endocrinologist for optimal glycemic management

---

2. Reduced Knee Joint Mobility — OA (b710)

• Physiotherapist to perform passive ROM exercises for knee daily, even while bedridden
• Apply knee positioning splint/pillow in slight flexion to reduce stiffness
• Progress to active-assisted ROM as medical condition stabilizes
• Apply heat therapy (if not contraindicated) to reduce joint stiffness before exercises
• Provide knee orthosis/brace during mobilization to support the joint

---

3. Muscle Weakness / ICU-Acquired Weakness (b730)

• Begin early mobilization protocol: head-of-bed elevation → sitting at edge of bed → standing → walking
• Physiotherapist to perform quadriceps isometric exercises and straight leg raises daily
• Use tilt table if patient cannot sit independently
• Neuromuscular electrical stimulation (NMES) of quadriceps if patient is sedated/immobile
• Ensure adequate protein intake (1.2–1.5 g/kg/day) to prevent muscle catabolism

---

4. Pain — Knee and Neuropathic (b280)

• Administer scheduled paracetamol (first-line; safe in DM) for OA knee pain
• Avoid NSAIDs due to renal risk with diabetic nephropathy
• Use gabapentin or duloxetine for neuropathic pain component (DM peripheral neuropathy)
• Apply ice packs to knee 15–20 min before physiotherapy sessions to reduce acute pain
• Use validated pain scale (NRS/VAS) to assess and document pain before and after activity

---

5. Fatigue / Low Energy (b130)

• Schedule rehabilitation sessions during patient's peak energy window (usually morning)
• Keep sessions short (15–20 minutes) and frequent rather than long and infrequent
• Correct nutritional deficiencies — check albumin, Hb, electrolytes; treat anaemia if present
• Ensure adequate sleep by minimizing ICU night-time interruptions where possible
• Gradually increase activity duration as tolerance improves (graded exercise)

---

6. Cardiovascular Risk / Blood Pressure Instability (b410, b420)

• Monitor heart rate and BP before, during, and after any mobilization activity
• Stop activity if HR >120 bpm, systolic BP >180 or <90 mmHg
• Coordinate with cardiologist if patient has known diabetic cardiomyopathy or ischemia
• Use telemetry during first few mobilization attempts
• Encourage deep breathing exercises to improve cardiovascular function while still in bed

---

7. Impaired Skin Integrity / Wound Healing Risk (b810)

• Perform 2-hourly repositioning to prevent pressure ulcers
• Use pressure-relieving mattress/overlay in ICU bed
• Inspect heels, sacrum, and bony prominences daily for early pressure injury signs
• Keep skin clean and dry; apply barrier cream to vulnerable areas
• Involve wound care nurse for any existing skin breakdown

---

8. Reduced Proprioception / Peripheral Neuropathy (b260, b840)

• Perform daily sensory assessment of lower limbs (monofilament, vibration)
• Use anti-slip footwear or socks during all mobilization activities
• Perform balance and proprioception re-training exercises (sitting balance → standing balance)
• Ensure bed rails are up and call bell is within reach at all times
• Educate patient and nursing staff about fall risk due to neuropathy

---

9. Psychological Distress / ICU Delirium / PICS Risk (Personal Factor)

• Screen daily using CAM-ICU (Confusion Assessment Method) for delirium
• Orient patient to time, place, and person regularly; provide clock and calendar in room
• Allow family visitation as per ICU policy to reduce anxiety and isolation
• Encourage patient participation in decision-making to restore sense of control
• Refer to clinical psychologist if signs of anxiety or depression are present
• Maintain day-night cycle: reduce lights and noise at night

---

10. Limited Mobility / Fall Risk in ICU Environment (d410–d450)

• Use assistive device appropriate to patient: walker, gutter frame, or wheelchair
• Fit patient with knee orthosis before standing/walking practice
• Ensure physiotherapist and nurse assist during first mobilization attempts
• Clear lines, tubes, and equipment to create safe mobilization space
• Conduct supervised transfer training: bed → chair → toilet progressively

---

Quick Reference Summary

---

In ICF terms: Facilitators are factors that — when actively put in place — reduce the impact of impairment and help the patient move from disability toward functioning. Each action above directly targets the corresponding body function impairment to maximize recovery and prevent secondary complications.

Goals of Treatment

---

SHORT-TERM GOALS (ICU Phase — 0 to 7 days)

Medical Stabilization

• Achieve glycemic control: blood glucose 140–180 mg/dL in ICU setting
• Treat and stabilize the primary condition leading to ICU admission (infection, DKA, acute illness)
• Prevent ICU-acquired complications: DVT, pressure ulcers, aspiration pneumonia, sepsis
• Maintain hemodynamic stability: HR, BP, SpO₂ within safe parameters

Physiotherapy / Rehabilitation

• Maintain full passive ROM of knee joint to prevent further stiffness and contracture
• Prevent ICU-acquired weakness (ICUAW) through bed exercises: ankle pumps, isometrics, SLR
• Achieve sitting at edge of bed independently or with minimal assistance
• Maintain respiratory function: deep breathing exercises, airway clearance if needed

Nursing / Skin Care

• Maintain intact skin integrity — zero pressure injuries
• Ensure adequate nutritional support (enteral/parenteral as appropriate)
• Maintain bowel and bladder function; prevent urinary tract infection

Psychological

• Prevent ICU delirium — maintain orientation, day-night cycle
• Reduce patient anxiety through communication, family contact, and reassurance

---

MEDIUM-TERM GOALS (Ward Phase — 1 to 4 weeks)

Mobility & Function

• Achieve independent or supervised standing and weight-bearing through both lower limbs
• Walk minimum 10–15 metres with appropriate assistive device (walker/stick) by discharge
• Improve knee ROM: target 0–90° flexion for functional activities (sit-to-stand, climbing stairs)
• Achieve independent bed-to-chair and chair-to-toilet transfers

Pain Management

• Reduce knee pain score from baseline to ≤3/10 on NRS during activity
• Establish effective oral analgesic regime (paracetamol ± gabapentin) safe for diabetic patient
• Patient able to participate in physiotherapy sessions without pain limiting activity

Metabolic Control

• Transition from IV insulin infusion to subcutaneous insulin/oral hypoglycemics
• Achieve fasting blood glucose <130 mg/dL and post-prandial <180 mg/dL on ward
• Patient able to self-monitor blood glucose with minimal assistance

Self-Care

• Patient able to perform basic ADLs (washing, grooming, dressing upper body) independently
• Patient able to perform diabetic foot inspection daily with adaptive equipment if needed
• Patient educated on pressure relief for heels and lower limbs

Education

• Patient and family educated on:
  • Diabetic diet and insulin administration
  • OA knee — activity modification, joint protection techniques
  • Fall prevention strategies
  • Signs of wound infection, hypoglycemia/hyperglycemia

---

LONG-TERM GOALS (Community/Home Phase — 1 to 6 months)

Independence & Participation

• Return to pre-morbid level of independence in ADLs and household activities
• Resume community ambulation: walking in neighbourhood, managing stairs
• Return to meaningful social and leisure activities (family involvement, outings)
• Achieve independent diabetes self-management: glucose monitoring, medication, diet

OA Knee Management

• Maintain or improve knee ROM ≥ 100° flexion for full functional activities
• Strengthen quadriceps to reduce joint load: target normal quadriceps power (grade 5/5)
• Reduce frequency and intensity of knee pain episodes
• Delay or avoid need for knee replacement surgery through conservative management

Metabolic & Cardiovascular

• Achieve HbA1c < 7.0–7.5% (individualized for elderly patient)
• Prevent diabetic complications: nephropathy, retinopathy, neuropathy progression
• Manage cardiovascular risk: BP <130/80 mmHg, lipid targets met
• Achieve and maintain healthy weight to reduce knee joint loading

Quality of Life

• Patient reports satisfaction with functional level and pain control
• Absence of re-hospitalization within 90 days
• Patient able to participate in a supervised community exercise or cardiac rehabilitation program
• Psychological well-being restored — screen negative for depression at 3-month follow-up

---

SMART Goal Summary Table

---

Underlying Principle

All goals follow the SMART framework — Specific, Measurable, Achievable, Relevant, Time-bound — and are aligned with the ICF model: addressing body function impairments, restoring activity performance, and maximizing participation in life roles appropriate for a 69-year-old male.