ICF Australian User Guide V1.0

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10.    ICF applications - examples

10.3    The ICF and classification for disability athletics

Introduction

It has been widely advocated that four of the classification systems currently used in disability athletics (i.e. track and field) should be replaced by a single, unified classification system. The purpose of this module is to:

• provide a brief overview of classification in disability athletics

• establish a rationale for basing a single, unified system on the language and structure of the ICF

• provide specific examples of how the ICF can be applied to enhance the utility and taxonomic integrity of a single unified system.

This module is based on a published paper entitled Taxonomic Theory and the ICF: Foundations for a Unified Disability Athletics Classification (Tweedy 2002).

Sport plays an important role in the lives of people with a disability, providing a valuable, self-directed means of enhancing rehabilitation and long-term health, as well as offering opportunities for recreation, social interaction, and the pursuit of athletic excellence. In 1948 the first Stoke Mandeville Games for Paralysed Individuals, forerunner of the modern Paralympic Games, were held (Vanlandewijck & Chappel 1996). Recognising that competitors would experience differing degrees of disadvantage in sport, the Games were organised so that athletes experiencing similar degrees of disadvantage competed against each other. The aim was to make competition fair, so that athletes who experienced greater disadvantage in sport were not precluded from success. For example, people with quadriplegia competed against each other and did not have to compete against people with paraplegia. The methods for placing athletes into groups were based on conventional medical assessment procedures.

Disability sport now includes people with a wide range of health conditions and impairments, and systems of classification remain a vital yet controversial feature of disability sport (Sherrill 1999; Vanlandewijck & Chappel 1996) playing an important role from international sport to local 'come and try' days. In general, the purpose of disability sports classification systems is twofold (Tweedy 2002):

• to define eligibility

• to ensure competition among eligible athletes is fair (i.e. that athletes are not precluded from success solely because of the disadvantage they experience as a result of their impairment).

Athletics (i.e. track and field) is one of the most popular organised sports for people with disabilities. This section focuses on four of the systems currently used in disability athletics at the Paralympic Games and many other national, state and local competitions throughout the world. The systems are those of the Cerebral Palsy-International Sport and Recreation Association (CP-ISRA 2001), the International Stoke Mandeville Wheelchair Sports Federation (ISMWSF 1995, 2000) and the International Sports Organisation for the Disabled (ISOD 1993). The latter has one system for amputees and one system for 'les autres'¹⁰. Table 10.4 presents a brief synopsis of people who are currently eligible to compete under the auspices of these organisations.

For a number of years it has been advocated that the four systems presented in Table 10.4 be replaced by a single, unified system. Such a move would streamline the process of classification, as well as provide an opportunity to improve taxonomic integrity and eliminate inconsistencies and ambiguities that currently exist.

Taxonomically, the ICF and the current disability athletics systems are very closely related. They are all classifications of the functioning and disability associated with health conditions, although they vary considerably in terms of breadth of scope.

The ICF is a very broad classification. Its universe encompasses all aspects of human health and some health-relevant components of wellbeing. It is not only about persons with disabilities, but all persons. The framework of the ICF organises information into two parts (Functioning and disability; and Contextual factors) and their respective components and domains (WHO 2001). This framework is used to describe the universe of the ICF, providing a structure for the meaningful organisation of information (WHO 2001).

In contrast, the disability athletics classifications are very narrow in focus. Their collective universe is limited to people with certain health conditions and/or impairments (see Table 10.4) and to those aspects of human health that relate directly to the activities within the athletic disciplines (i.e. running, jumping, throwing and wheelchair racing). In other words, the scope of the athletics classification systems can be fully described by a small number of the Body functions and structures and Activity domains of the ICF (expressly discussed later in this section).

Linking the development of the highly specific disability athletics classification system to the broad classificatory framework of the ICF has the potential to improve the utility of both systems and to advance understanding of the functioning and disability associated with health conditions.

It would be beneficial to base a unified disability athletics system on the ICF because the ICF provides a well-constructed, taxonomically sound structure and uses standardised definitions that are actively promoted, widely utilised and have been translated into several different languages. Use of the ICF as framework for a unified athletics classification would minimise ambiguity, enhance conceptual clarity and maximise understanding, particularly among non-English speaking stakeholders in the international disability sport community.

Conversely, the ICF benefits from wide use; justification for the development and maintenance of broad classificatory frameworks such as the ICF depend on their widespread application (Fleishman & Quaintance 1984). Moreover, if the ICF were used in the development of a unified athletics system, there would be potential to expand and develop specific domains within the ICF. For example, a new unified disability athletics classification system could expand and enhance relevant Activities codes, specifically those for running (a4552), jumping (a4553), throwing (a4454) and wheelchair propulsion (a465). Empirical evidence suggests that such 'fractionalising' enhances the usefulness of primary categories in broader, more general systems such as the ICF (Fleishman & Quaintance 1984).

Using the ICF, the purpose, structure and language of the four current disability athletics systems have been identified. The remainder of this section identifies areas of weakness in the four current systems and indicates how the language and structure of the ICF could be applied to overcome these weaknesses in a unified disability athletics classification.

The clarity and effectiveness of the eligibility criteria presented in Table 10.4 are compromised by use of terms that are not standardised, such as 'functionally be equated' (ISMWSF system), 'similar conditions' (CP-ISRA system), and 'resembling' (ISOD amputee system). For example, it is surely a matter of debate as to which disabilities can functionally be equated with spinal cord injury. Such potential areas for debate would considerably weaken the integrity of a unified system.

Use of the clearly defined, mutually exclusive ICF codes could be used to help define eligibility and improve the clarity of the system. For example, the codes b710 - b799 (Neuromusculoskeletal and Movement-Related Functions), s110 - s199 (Structures of the Nervous System), and s710 - s799 (Structures Related to Movement) best describe the populations covered by the four current systems and would be the most appropriate starting point.

In each of the current disability athletics systems, it is possible for an athlete to have a health condition or impairment type that satisfies eligibility criteria but to be ruled ineligible on the grounds that he or she does not meet other criteria, commonly called 'minimum disability' criteria. In column 2 of Table 10.5 the criteria used by each of the current systems are presented. In the lexicon of the ICF, the term 'minimal disability' does not accurately describe the eligibility criteria stated by the respective organisations. Column 3 of Table 10.5 presents a more accurate description of each of the criteria. In a unified system it would be important to ensure that the descriptor used for this area of classification was stated accurately in terms consistent with the ICF.

Column 4 of Table 10.5 presents the rationale that each organisation presents for establishing minimal disability criteria. There are obvious discrepancies and gaps in the rationale establishing minimal disability criteria in each of the current systems, highlighted by the fact that no rationale is offered by ISMWSF. A necessary prerequisite for the establishment of a unified system would be documentation of a sound rationale for and description of minimum disability criteria stated in terms consistent with the ICF.

§ The ISOD 'les autres' system is not presented in this table or included in the analyses based on this table. This is becasue the 'les autres' system has a very weak concpetual basis, a fact highlighted by the current IPC policy of using the 'les autres' system to define eligibility but not to place athletes into classes. Instead, athletes who are permitted to compete in disability athletics under 'las autres' criteria are placed into classes using the Amputee or ISMWSF systems.

To ensure the conceptual basis of the current systems of classification are not significantly altered or lost in the development of a unified system, they need to be clarified. This example illustrates how the ICF can be used for this purpose. A précis of the methods used for placing athletes into classes is presented in column 4 of Table 10.5. In general, the conceptual basis of each of the current systems is quite clear and logical. When eligibility of an athlete for a system of classification is defined in terms of the type of health condition or impairment, then the methods used to assess the impairment will be relatively uniform, allowing comparison of results and providing a sound basis for grouping athletes into classes.

A misconception about the conceptual basis of these systems is that they classify (or control for) the extent of impairment of an athlete. However this phrase is taxonomically inconsistent with the ICF, being predicated on the outdated notion that activity limitation is caused by impairment. The phrase implies that, by measuring impairment, the activity limitation experienced by a person can be predicted. In the ICF, the impairment and activity dimensions are interdependent (WHO 2001:18, Fig. 1); impairment does not cause activity limitation (WHO 2001). Moreover, the ICF removes the ambiguity previously associated with the term impairment, using it only to describe limitations in the domains of body structure or body function. Activity limitations (not impairments) refer to difficulties experienced by a whole person; therefore, the term whole-person impairment (used in some quarters of disability sport) is not valid in the ICF lexicon. Although a range of methods can be used to quantify the impairment of discrete structures or functions, it is not a simple matter of converting an amount of impairment into an amount of activity limitation. The process of evaluating how much a given quantity of impairment will affect the activity of a whole person must begin by defining the activity.

To illustrate, Person A and Person B may both have spinal cord lesions that paralyse 50% of their musculature, resulting in the same total score using the ISMWSF muscle chart. Quantitatively, these persons could be said to have the same extent of impairment. However, if the distribution of the paralysed muscles is spread over the upper and lower body (including the small muscles of the hand) in Person A and restricted solely to the lower body in Person B, then it is likely Person A will be less impaired in the activity of walking/running, but more impaired in the activity of throwing a ball, than Person B is. In this case, a correct restatement of the comparison of Persons A and B is that Person A experiences less activity limitation in walking and greater activity limitation in throwing a ball than Person B does.

As identified in Table 10.5, the current disability athletics systems take account of both observable activity limitation and assessment of impairment. If a unified system is to remain consistent with the conceptual bases of current classification processes (as interpreted using the ICF framework), then its definitive role should be estimation of the extent of activity limitation resulting from impairment. Assessment of impairment alone is not sufficient because the effects of impairment only make sense when interpreted in light of a specific activity. Assessment of activity limitation alone is not sufficient because there are many factors other than impairment that influence activity limitation. Based on the extent of activity limitation resulting from impairment, eligibility can be decided, and eligible athletes can be placed into classes with athletes who experience similar extent of activity limitation to enable fair competition.

Each of the four current systems of disability athletics classification refers to the process of classifying athletes, thereby making people the units of classification. A more contemporary and socially sensitive view of classification argues that people should not be characterised solely in terms of a classification (WHO 2001). Accordingly, the ICF does not classify people. Rather, the unit of classification is categories within each domain. Adoption of ICF categories as the units of classification in a unified disability athletics system would be consistent with the purpose of the system while improving social sensitivity.

This section outlines how the broad, generalisable taxonomy and standardised language of the ICF may be used to expose inconsistencies and clarify the conceptual bases of the current systems and thus to provide guidelines for developing a new unified system of classification. Such a system will be effective in achieving its intended purpose.

The author's studies are made possible through the generous support of the Centre of National Research on Disability and Rehabilitation Medicine (CONROD), Australia.

10 les autres is a French term meaning the others.

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