Applying the ICF framework in severe traumatic brain injury: functional profiling to guide multidisciplinary rehabilitation—a case report

Abstract

Background

Traumatic brain injury is a leading cause of long-term disability and often results in complex physical, cognitive, and psychosocial challenges. Rehabilitation must be individualized and multidisciplinary. This case report demonstrates the application of the International Classification of Functioning, Disability and Health (ICF) framework in developing a comprehensive functional profile, facilitating goal setting, and supporting multidisciplinary rehabilitation planning in severe traumatic brain injury.

Case presentation

A 35-year-old South Indian male sustained severe traumatic brain injury and multiple injuries following a road traffic accident. On admission, he presented with deep coma. Neuroimaging revealed bilateral frontal and cerebellar contusions, extradural and subdural hematomas, subarachnoid hemorrhage, cerebral edema, skull fractures, and thoracic injuries. Clinical swallow evaluation indicated severely impaired oral and pharyngeal reflexes. He underwent acute neurosurgical and medical management, followed by a multidisciplinary neurorehabilitation program. Functional assessment using the ICF framework identified deficits in mental functions, neuromusculoskeletal and movement-related functions, sensory functions, swallowing, and activities of daily living. ICF qualifiers guided the formulation of individualized rehabilitation goals addressing arousal, orientation, motor control, communication, swallowing, and daily function. The ICF framework was used to identify impairments, activity limitations, participation restrictions, and environmental factors relevant to rehabilitation planning. The resulting functional profile guided individualized goal setting within the multidisciplinary team. Over, the course of rehabilitation, the patient progressed from a minimally conscious state to achieving basic orientation, oral feeding with compensatory strategies, and functional communication.

Conclusions

This case highlights the practical application of the ICF framework in comprehensively profiling functioning and disability following severe traumatic brain injury. The framework facilitated structured assessment, interdisciplinary communication, and individualized goal setting within a multidisciplinary rehabilitation context.

Background

Traumatic brain injury (TBI) remains a significant cause of disability worldwide, resulting in impairments across physical, cognitive, emotional, and social domains [1]. The complex interplay of injury severity, systemic trauma, and environmental factors makes recovery highly individualized and variable across patients [2]. In this context, the International Classification of Functioning, Disability and Health (ICF) provides a comprehensive framework which integrates the biomedical, personal and societal dimensions of health, enabling the clinicians to address impairments, activity limitations, participation restrictions, and environmental factors relevant to rehabilitation [3].

The development of ICF Core Sets for TBI has enabled systematic assessment and rehabilitation planning, offering a standardized set of essential categories for this population [4]. Incorporating the ICF into clinical practice facilitates consistent documentation, interdisciplinary communication, and individualized goal setting, thereby supporting a patient-centered approach to neurorehabilitation [5]. Furthermore, the creation of formal linking rules has enhanced the reliability of mapping clinical observations to ICF categories, strengthening its use as a structured tool for assessment and outcome tracking [6].

The present case report illustrates the practical application of the ICF framework in guiding assessment, goal formulation, and monitoring of functional recovery in a patient with severe TBI, highlighting its value in structuring interdisciplinary rehabilitation.

Case presentation

A 35-year-old South Indian male presented following a high-velocity road traffic accident, with a chief complaint of loss of consciousness and polytrauma. Prior to the injury, the patient had no significant past medical or surgical history and was engaged in vocational activities with supportive family dynamics. Family history was non-contributory. Upon arrival at the emergency department, he was unconscious with a Glasgow Coma Scale (GCS) score of E1 M2 VEt (3 T/15), reflecting a severe level of impaired consciousness. Clinical examination revealed diminished pupillary reflexes, severely restricted spontaneous limb movements, and deranged vital parameters, necessitating immediate airway protection via tracheostomy and mechanical ventilation.

Initial neuroimaging through Computed Tomography (CT) demonstrated extensive intracranial injuries, including bilateral frontal contusions, a left cerebellar hemorrhage, a right basifrontal epidural hematoma, multifocal subdural hematomas, diffuse subarachnoid hemorrhage, and cerebral edema, accompanied by multiple skull fractures. Additional systemic injuries were identified, notably a pneumothorax managed with an intercostal drainage tube, bilateral pleural effusion, multiple rib fractures, and a right femoral fracture, which further complicated the acute clinical course (Fig. 1).

Fig. 1.

Sequential overview of the patient’s evaluation

Following stabilization, the patient underwent a comprehensive functional assessment based on the ICF framework.

Timeline

Functional assessment using ICF framework

Speech, language, and swallowing were comprehensively evaluated using the ICF framework to identify impairments secondary to TBI. Domain-specific categories related to communication and ingestion were rated using standardized qualifiers, reflecting the severity of functional deficits. This structured profiling informed the development of a targeted, patient-centered rehabilitation plan. The following tables outline the ICF domains assessed and corresponding qualifier ratings. In addition to the ICF framework, serial Glasgow Coma Scale (GCS) assessments and clinical bedside swallowing evaluations were used to monitor patient progress. Owing to the patient's minimally conscious state and limited verbal output, standardized neurocognitive and swallowing assessments were not feasible during the early stages of rehabilitation.

Functional assessment

ICF qualifiers were assigned based on clinical examination, caregiver reports, review of medical records, and multidisciplinary clinical observations in accordance with WHO ICF guidelines. Qualifier ratings ranged from 0 (no problem) to 4 (complete problem). The primary objective of this assessment was to develop a structured functional profile that could guide rehabilitation goal setting and interdisciplinary management.

The speech-language pathologist (SLP) primarily made ICF assessment and qualifier assignment. In order to ensure the accuracy of the data in ICF categories and assignment of qualifiers, the ratings assigned by the primary speech-language pathologist in collaboration with professionals from Physical Medicine Rehabilitation Ward was scrutinized by manual ross verification by a senior speech-language pathologist in the same field (Table 1).

Table 1.

ICF-based functional profile: body functions

Qualifier scale: 0 = No problem; 1 = Mild problem; 2 = Moderate problem; 3 = Severe problem; 4 = Complete problem. Qualifiers were assigned according to WHO ICF guidelines to develop a functional profile for rehabilitation planning and goal setting

The patient exhibits severe deficits in body functions, including impaired consciousness (b110), orientation (b114), and temperament/personality (b126), indicative of frontal lobe damage. Deficits in attention (b140) and memory (b144) are linked to cerebellar and frontal hemorrhages. Language functions (b167), speech functions (b310, b320, b330), and swallowing (b510) are also significantly impaired due to traumatic brain injury, along with ventilator support, and tracheostomy (Table 2).

Table 2.

ICF-based functional profile: body structures

Qualifier scale: 0 = No problem; 1 = Mild problem; 2 = Moderate problem; 3 = Severe problem; 4 = Complete problem

Traumatic brain injury has caused substantial damage to brain structures (s110), including hemorrhages and contusions. The craniofacial region (s710) shows disruption from skull fractures, while the oral cavity (s320), pharyngeal area (s340), and pulmonary system (s430) are compromised, contributing to difficulties in swallowing, articulation, and respiratory function (Table 3).

Table 3.

ICF-based functional profile: activities and participation

Qualifier scale: 0 = No problem; 1 = Mild problem; 2 = Moderate problem; 3 = Severe problem; 4 = Complete problem

The patient faces significant challenges in complex problem-solving, attention, and information processing, which impact his communication and social participation. These impairments result from cognitive and communicative difficulties associated with the neurological injury (Table 4).

Table 4.

Environmental factors influencing functioning and rehabilitation

Environmental factor scale: positive values (+ 1 to +4) indicate facilitators, while values (1 to 4) indicate barriers affecting functioning and participation according to WHO ICF guidelines

Supportive environmental factors include nutritional support (e1100), adaptive feeding tools (e135), and assistive devices (e115), facilitating recovery. The involvement of healthcare professionals (e355) is crucial for rehabilitation, while family support (e410) plays a key role in the patient’s emotional recovery and engagement in rehabilitation.

The purpose of these tables is to provide a structured functional profile of the patient to support multidisciplinary goal setting and rehabilitation planning using the ICF framework (Table 5).

Table 5.

Rehabilitation timeline and functional milestones

Timepoint	Rehabilitation interventions	Functional milestones/outcomes
Day 0	Initial stabilization following severe TBI	Loss of consciousness; GCS: E1M2VEt (3 T/15)
Days 1–10	Neurocritical care, mechanical ventilation, supportive management	Continued medical stabilization
Week 2	Surgical tracheostomy and ongoing neuro-monitoring	Persisting minimally conscious state
Week 3	Transfer to PMR unit; initiation of physiotherapy, occupational therapy, and speech-language pathology services	Commencement of structured multidisciplinary rehabilitation
Weeks 3–4	Swallowing rehabilitation (3 sessions/day): lemon swabs, thermal-tactile stimulation, T-tube chewing exercises; cognitive-linguistic intervention (2 sessions/day) targeting arousal and responsiveness	Increased alertness and responsiveness; recognition of familiar individuals and positive emotional responses
Weeks 4–6	ICF-based functional profiling and individualized goal setting; graded oral feeding trials with SpO₂ monitoring	Progression to oral intake with thin liquids (IDDSI Level 0) and semisolid consistencies
Week 6 onward	Continued multidisciplinary rehabilitation and tracheostoma closure	Emerging vocalizations and occasional meaningful verbal output
Follow-up	Ongoing physiotherapy and speech-language rehabilitation	GCS improved to E4V3M6 (13/15); progression to IDDSI Level 6 (soft and bite-sized foods); supported standing with physiotherapy assistance; improved participation in social interactions

Rehabilitation approach

The patient was placed in a rehabilitation program for neurorehabilitation aimed at the comprehensive treatment of various impairments caused by a severe TBI after the functional assessment was performed. It should be noted that although the focus of this case report is ICF-based functional profiling, some aspects of rehabilitation will be briefly mentioned in order to demonstrate the changes in functioning and participation associated with the process of rehabilitation. According to the framework of the International Classification of Functioning, Disability and Health (ICF), intervention programs include different areas, such as cognition, language, motor skills, sensations, and psychosocial functions, as well as their interaction. Swallowing therapy was performed thrice a day according to the safety and tolerability of the patients using graded oral feeding with sensory stimulation. The cognitive-linguistic treatment was performed twice daily depending on the awareness and cooperation of the patients; whether before or after swallowing therapy. The therapies aimed at increasing arousal, orientation, attention, responsiveness, and effective communication skills through structured stimulation exercises. Some of the structured stimulation exercises involved orientation to persons, place, and time; presence of familiar voices and objects; simple following commands; and interaction by caregivers.

Improvements were made gradually during rehabilitation. Upon arrival at the emergency department, he was unconscious with a GCS score of E1 M2 VEt (3 T/15), reflecting a severe level of impaired consciousness. The patient was introduced to early sensory interventions, including lemon swabs, thermal and tactile stimuli, chewing via T-tubes, and cognitive-linguistic stimulation. The evaluation of cognitive functions during this period was clinical, which means that assessments of cognitive function were not conducted formally. The last stage of the patient’s treatment process saw an increase in the GCS score to E4V3M6 (13/15). It shows that the consciousness of the patient greatly improved during this period. The training of swallowing included progressing from regulated intake of thin fluid diet (IDDSI level 0) to semisolid and solid diets (IDDSI level 6). There was close observation of the person's SpO2 and signs of aspiration. Following the closure of tracheostomy, vocalization and occasional meaningful words (minimal) could be detected.

A formal test for cognitive abilities could only be carried out once the individual regained sufficient consciousness and cooperation. Given that cognitive tests yielded little information, due to low verbal responses, cognitive abilities were assessed based on clinical observation within the ICF approach. Improvement was noted in relation to body function, activities, and participation. Besides, with the aid of physiotherapists, the individual could go from lying position to supported standing position.

Discussion

This case highlights the multidimensional nature of traumatic brain injury (TBI) and underscores the importance of applying a biopsychosocial framework, such as the International Classification of Functioning, Disability and Health (ICF), to rehabilitation. TBI remains one of the leading causes of long-term disability worldwide, contributing significantly to health and socioeconomic burdens across populations [1, 2]. Traditional severity-based models often fail to capture the complexity of post-injury functioning; in contrast, the ICF offers an integrative framework that bridges medical, functional, and social dimensions of recovery [3].

The primary purpose of the present report was not to evaluate rehabilitation efficacy but to demonstrate the practical application of the ICF framework in the functional assessment of a patient with severe traumatic brain injury. By systematically documenting impairments, activity limitations, participation restrictions, and environmental factors, the ICF framework supported the development of a comprehensive functional profile that informed goal setting and interdisciplinary rehabilitation planning.

The ICF framework emphasizes the interconnectedness of body functions, body structures, activities, participation, and environmental as well as personal factors, promoting a holistic understanding of health conditions [5]. Its use in the present case enabled comprehensive mapping of the patient’s impairments and facilitators, leading to individualized, goal-oriented rehabilitation. The systematic categorization of functional deficits using the ICF Core Set for TBI [4] revealed pronounced impairments in consciousness, orientation, personality functions, and communication findings consistent with prior literature on outcomes following severe TBI [2, 7].Cognitive and communicative impairments observed in this case particularly in attention, memory, and language reflect the central role of functional cognition in predicting long-term participation outcomes. Donovan et al. [7] emphasized that even subtle deficits in cognitive communication significantly affect reintegration into daily activities and social roles. Similarly, the gradual recovery pattern documented here illustrates that functional improvements are interdependent: restoration of basic attention and arousal preceded advances in communication and social participation, reinforcing the hierarchical and dynamic nature of neurocognitive recovery [2]. Environmental supports played a pivotal role in facilitating progress. Family involvement, consistent therapeutic engagement, and structured rehabilitation settings served as positive contextual facilitators, in line with evidence that supportive environments substantially mediate functional outcomes in acquired brain injury [8]. The ICF’s explicit inclusion of environmental and personal factors provided a structured means to recognize, document, and leverage these facilitators throughout rehabilitation. While standardized outcome measures may complement ICF-based assessment by providing additional quantitative information, the present case report was designed to demonstrate the application of ICF qualifiers for functional profiling rather than outcome evaluation. The resulting functional profile supported goal setting and interdisciplinary rehabilitation planning within a multidisciplinary team setting. Overall, this case reinforces growing consensus that integrating the ICF framework into TBI rehabilitation enhances the depth, consistency, and patient-centeredness of care [4, 5]. By systematically capturing body functions, activities, participation, and contextual influences, the ICF enables clinicians to identify meaningful changes beyond symptom reduction. As to be noted limitation to the current study is that, there is a lack of serial assessments at definite timepoints. This limits a detailed longitudinal tracking of functional recovery across ICF domains. However, the current report highlights the patient’s trajectory from coma to emerging communicative participation illustrating the potential value of function-oriented rehabilitation in structured clinical settings, individualized rehabilitation guided by the ICF. Such integration supports a paradigm shift from treating isolated impairments to promoting holistic recovery and participation in life after TBI. It is also to be noted that, this study is a single case report and the findings should be interpreted with caution. Although there are numerous advantages of using the ICF framework in functional profiling, its use may face certain difficulties because of constraints in time, skills, and evaluation capacity. However, even considering the existence of all these obstacles, the utilization of the ICF framework is a valuable tool for facilitating interdisciplinary communication and patient-centric rehabilitation. The current case report intends to illustrate the clinical application of the ICF framework rather than to establish broader clinical efficacy or generalizability.

Conclusion

This case report illustrates the application of the ICF framework in developing a comprehensive functional profile following severe traumatic brain injury. The framework facilitated systematic documentation of functioning and disability, supported interdisciplinary communication, and assisted goal setting within a multidisciplinary rehabilitation team. Further studies may explore how ICF-based profiling can be integrated with standardized outcome measures to enhance clinical decision-making. Future research employing serial ICF-based assessments across multiple timepoints may provide a more comprehensive understanding of functional recovery patterns following rehabilitation.

Abbreviations

TBI

Traumatic brain injury

ICF

International classification of functioning, disability, and health

WHO

World Health Organization

GCS

Glasgow coma scale

CT

Computed tomography

ADL

Activities of daily living

ICD

International classification of diseases

Author contributions

Both authors contributed equally to the conception, design, data collection, analysis, and manuscript preparation of this study.

Funding

Open access funding provided by SRM Institute of Science and Technology for SRMIST – Medical & Health Sciences. The authors gratefully acknowledge the financial support by SRM School of Allied Health Sciences, Faculty of Medicine and Health Sciences, SRM Institute of Science and Technology for bearing the defrayed costs of publishing this article.

Data availability

All data generated or analyzed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

Ethical approval was not applicable. Informed consent to participate was obtained from the participant’s caregiver. Consent was provided by the caregivers initially and following recovery the signed consent for publishing this report was directly taken from the patient himself.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The author declares no competing interests.