Gerold Stucki, MD, MSc, Alarcos Cieza PhD, MPH

1
WHO ICFInternational Classification of
Functioning, Disability and Health

• Gerold Stucki, MD, MSc, Alarcos Cieza PhD, MPH
• ICF Research Branch, WHO CC FIC
  GermanyDepartment of Physical Medicine and
  RehabilitationLudwig-Maximilian University of
  Munich

2
Overview

• The WHO model of functioning and disability
• International Classification of Functioning,
  Disability and Health (ICF)
• ICF Core Sets
• Practical application of the ICF andthe ICF Core
  Sets

3
The bio-medical Model of disease
Health Condition(disease, trauma)
Functioning
4
The bio-medical Model of disease
Health Condition(disease, trauma)
Evaluation of the disease consequences
5
The integrative model of functioning and
disability
Health condition(disease, trauma)
Functioning
Environmental factors
Personal factors
Contextual factors
6
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ICD - 10 S 83.3 Tear of articular cartilage
of knee
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The integrative model of functioning and
disability
Health condition(disease, trauma)
Functioning
Environmental factors
Personal factors
Contextual factors
9
International Classification of Functioning,
Disability and Health ICF Approved by the World
Health Assembly in May 2001
10
The integrative model of functioning and
disability
Health condition(disease, trauma)
Functioning
Environmental factors
Personal factors
Contextual factors
11
The integrative model of functioning and
disability
Health condition(disease, trauma)
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
12
The integrative model of functioning and
disability
13
The integrative model of functioning and
disability
Health condition(disease, trauma)
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
14
The integrative model of functioning and
disability
Health condition(disease, trauma)
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
15
Health Condition

• A health condition is an umbrella term for
  disease, disorder, injury or trauma
• A health condition may also include other
  circumstances, such as ageing, stress, congenital
  anomaly, or genetic predisposition
• Health conditions are coded using the ICD-10

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The integrative model of functioning and
disability
Health condition(disease, trauma)
Tear of articular cartilage of kneeM 23.5
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
17
The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
18
Body Function Structure

• Body functions are physiological functions of
  body systems, including psychological functions
• Body structures are anatomical parts of the body,
  such as organs, limbs and their components
• Impairments

19
The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Activity
Participation
Cruciate ligament
Environmental factors
Personal factors
Contextual factors
20
The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Activity
Participation
Cruciate ligament
Environmental factors
Personal factors
Contextual factors
21
Activity Participation

• Activity is the execution of a task or action by
  an individual. It represents the individual
  perspective of functioning.
• Participation is involvement in a life situation.
  It represents the societal perspective of
  functioning.

• Activity limitations

• Participation restrictions

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The integrative model of functioning and
disability
Tear of articular cartilage of kneeM 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Take care of her grandchildDoing
houseworkAssisting her husband with his business
Carrying objects, kneeling, walking, climbing
Activity
Participation
Cruciate ligament
Environmental factors
Personal factors
Contextual factors
23
The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Take care of her grandchildDoing
houseworkAssisting her husband with his business
Carrying objects, kneeling, walking, climbing
Activity
Participation
Cruciate ligament
Environmental factors
Personal factors
Contextual factors
24
Environmental Factors

• Environmental factors make up the physical,
  social and attitudinal environment in which
  people live and conduct their lives
• Environmental factors are external to individuals
  and can have positive (facilitator) or negative
  (barrier) influence on the individual

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The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Take care of her grandchildDoing
houseworkAssisting her husband with his business
Carrying objects, kneeling, walking, climbing
Activity
Participation
Cruciate ligament
Environmental factors
Personal factors
Contextual factors
26
Personal Factors

• e.g. gender, age, race, fitness, lifestyle,
  habits, social background, other health
  conditions

27
The integrative model of functioning and
disability
Tear of articular cartilage of knee M 23.5
Pain, stability of joints,muscle power
Body functionand body structure
Take care of her grandchildDoing
houseworkAssisting her husband with his business
Carrying objects, kneeling, walking, climbing
Activity
Participation
Cruciate ligament
60 year oldMotivated
Environmental factors
Personal factors
Contextual factors
28
Functioning is the human experience in relation to
in the interaction with health conditions,
personal and environmental factors
29
Disability is the human experience of
in the interaction with health conditions,
personal and environmental factors
30
Optimal Functioning
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ICF provides an international common language and
universal conceptual framework for describing
functioning, disability and health
32
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Health condition(disease, trauma)
Body functionand body structure
Activity
Participation
Environmental factors
Personal factors
Contextual factors
34
Health condition(disease, trauma)
493 Body functionsand body structure
Activities Participations
Environmental factors
Personal factors
Contextual factors
35
Health condition(disease, trauma)
493 Body functionsand 310 structures
Activities Participations
Environmental factors
Personal factors
Contextual factors
36
Health condition(disease, trauma)
493 Body functionsand 310 structures
384 Activities Participations
Environmental factors
Personal factors
Contextual factors
37
Health condition(disease, trauma)
493 Body functionsand 310 structures
384 Activities Participations
253 Environmental factors
Personal factors
Contextual factors
38
Health condition(disease, trauma)
493 Body functionsand 310 structures
384 Activities Participations
253 Environmental factors
Personal factors
Contextual factors
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ICF Categories
Health condition(disease, trauma)
493 Body functionsand 310 structures
384 Activities Participations
253 Environmental factors
Personal factors
Contextual factors
40
ICF -- Structure
41
One-Level Classification
Body Structures (s)
Body Functions (b)
42
One-Level ClassificationActivities and
Participation (d)
43
One-Level ClassificationEnvironmental Factors (e)
44
ICF -- Structure
45
Two-Level Classification - Example

• Chapter b1 Mental functions
• Global mental functions (b110 b139)
• b110 Consciousness functions
• b114 Orientation functions
• b117 Intellectual functions
• b122 Global psychosozial functions
• b126 Temperament and personality functions
• b130 Energy and drive functions
• b134 Sleep functions
• b139 Global mental functions, other specified
  and unspecified
• Specific mental functions (b140 b189)

46
ICF
Look in your materials for b114 and e455 in
theTwo-Level Classificationp. 33 - 44

• Second-Level
• Classification

47
ICF -- Structure
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Detailed Classification with Definitions - Example

• Chapter b1 Mental functions
• b114 Orientation functions
• General mental functions of knowing and
  ascertaining ones relation to self, to
  others, to time and to ones surroundings.
• Inclusions functions of orientation to
  time, place and person orientation to self
  and others disorientation to time, place and
  person.
• Exclusions consciousness (b110)
  attention functions (b140) memory
  functions (b144).
• b1140 Orientation to time
• Mental functions that produce awareness
  of day, date, month and year
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• Mental functions that produce
  awareness of ones own identity

49
ICF
Look in your materials for b28014 and d4350 in
the Detailed Classificationp. 47 - 207

• Detailed Classification
• with Definitions

50
ICF -- Structure
ICF
Body Functions b
Body Structures s
Activity Participation d
Environmental Factors e
b1 b8
s1 s8
d1 d9
e1 e5
b110 b899
s110 s899
d110 d999
e110 e599
b1100 b7809 b11420 b54509
s1100 s8309 s11000 s76009
e1100 e5959
d1150 d9309
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ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
52
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
53
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
54
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
55
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
56
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
57
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
58
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
59
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
60
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
61
ICF Categories

• Example
• b1 Mental functions 1st level
• b114 Orientation functions 2nd level
• b1141 Orientation to place
• b1142 Orientation to person
• b11420 Orientation to self
• b11421 Orientation to others

3rd level
4th level
62
Contents
A. Introduction B. One-level classification C. Two
-level classification D. Detailed classification
with definitions E. Annexes F. Index
http//www3.who.int/icf/icftemplate.cfm
63
Contents and Structureof the ICF - Practice -
64
Case Study I
A 32-year-old woman, after a few hours of typing
and data entry on the computer ,
complained of pain , numbness
and tingling in both hands and
pain in wrists. She also experience some weakness
in her hands , which caused her to drop
objects. An EMG was performed and she was
diagnosed with Carpal Tunnel Syndrome (G56.0).

• Which component?
• Which chapter within the selected component is
  the most appropriated?
• Which category within the selected chapter is the
  most precise?

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Case Study I
A 32-year-old woman, after a few hours of typing
and data entry on the computer d360, complained
of pain b280, numbness b265 and tingling b265 in
both hands and pain in wrists. She also
experience some weakness in her hands b730, which
caused her to drop objects. An EMG was performed
and she was diagnosed with Carpal Tunnel Syndrome
(G56.0).
d360 Using communication devices and
techniques b280 Sensation of pain b265 Touch
function b730 Muscle power functions
66
Case Study II
A 28-year-old woman, a housekeeper in a hotel,
complains of tight shoulder pain_________. She
has extreme difficulty carrying things with her
right arm ___ . She has severe problems to
perform her Work in the hotel
and to take care of her 6-month old child
. Without the help of his colleagues
she would already be on sick leave. She has pain
at night if she sleeps on the right side. She has
got used to sleep on the left side. Therefore she
sleeps well . On exam she has
weakness rotating her shoulder to the
outside and away from the body. The diagnosis of
Rotator cuff syndrome (M75.1) was made. She was
give subacromial injection and a
physical therapy program . Her
pain was dramatically better.
67
Case Study II
A 28-year-old woman, a housekeeper in a hotel,
complains of tight shoulder pain_b28016. She has
extreme difficulty carrying things with her right
arm d430. She has severe problems to perform her
Work in the hotel d850 and to take care of her
6-month old child d660. Without the
help of his colleagues e325 she would already be
on sick leave. She has pain at night if she
sleeps on the right side. She has got used to
sleep on the left side. Therefore she sleeps well
b134. On exam she has weakness rotating her
shoulder b710 to the outside and away from the
body. The diagnosis of Rotator cuff syndrome
(M75.1) was made. She was give subacromial
injection e1101 and a physical therapy program
e580. Her pain was dramatically better.
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Until now the ? was

• ? Qualifiers

• what is the extent of the problem

• what is the problem

and now the ? is
3
b1141.
0
1
2
4
8
9
69
Uniform or generic scale (qualifier)

• 0 NO problem (none, absent, negligible,...)
  0-4
• 1 MILD problem (slight, low,...) 5-24
• 2 MODERATE problem (medium, fair...) 25-49
• 3 SEVERE problem (high, extreme,...) 50-95
• 4 COMPLETE problem (total,...) 96-100
• 8 not specified (the available information does
  not suffice to specify the severity of the
  problem)
• 9 not applicable (it is inappropriate or not
  possible to apply the code)

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ICF
0 NO problem (none, absent, negligible,) 0-4 1
MILD problem (slight, low,...) 5-24 2
MODERATE problem (medium, fair...) 25-49 3
SEVERE problem (high, extreme,...) 50-95 4
COMPLETE problem (total,...) 96-100
8 not specified (the available information does
not suffice to specify the severity of the
problem) 9 not applicable (it is inappropriate or
not possible to apply the code)
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ICF
72
Case Study II
A 28-year-old woman, a housekeeper in a hotel,
complains of tight shoulder pain_b28016.2. She
has extreme difficulty carrying things with her
right arm d4302.3. She has severe problems to
perform her Work in the hotel d850.3 and to take
care of her 6-month old child d6600.3.
Without the help of his colleagues e325.3 she
would already be on sick leave. She has pain at
night if she sleeps on the right side. She has
got used to sleep on the left side. Therefore she
sleeps well b134.0. On exam she has weakness
rotating her shoulder b710.2 to the outside and
away from the body. The diagnosis of Rotator cuff
syndrome (M75.1) was made. She was give
subacromial injection e1101.3 and a physical
therapy program e355.3. Her pain was
dramatically better.
73
Case Study III
A 40 year old woman with a whiplash injury 4
months earlier complains about very strong pain
in the neck , severe headache
, dizziness , slightly reduced muscle
power and mild anxiety .
The X-ray shows distorsion of the ligaments of
neck region . Her ability to walk
, cook , clean,
handle a computer and drive a car
are reasonable limited. In consultation with
her physician it was mutually agreed to wait till
the problems are reduced before she can return to
her old full-time fixed-hours job. She is on sick
leave, since she can not hold down her job
as a secretary and the workplace policies
does not allow her for flexible work
hours, and to work from home.
74
Case Study III
A 40 year old woman with a whiplash injury 4
months earlier complains about very strong pain
in the neck b28010, severe headache b28010,
dizziness b2401, slightly reduced muscle
powerb730 and mild anxiety b152. There is a
moderate distorsion of the ligaments of neck
region s7105. Her ability to walk d450, cook
d630, clean, handle a computer and drive a car
d4751 are reasonable limited. In consultation
with her physician it was mutually agreed to wait
till the problems are reduced before she can
return to her old full-time fixed-hours job. She
is on sick leave, since she can not hold down her
job d850 as a secretary and the workplace
policies e5902 does not allow her for flexible
work hours, and to work from home.
75
Case Study III
A 40 year old woman with a whiplash injury 4
months earlier complains about very strong pain
in the neck b28010.3, severe headache b28010.3,
dizziness b2401, slightly reduced muscle power
b730.1 and mild anxiety b152.1. There is a
moderate distorsion of the ligaments of neck
region s7105.2. Her ability to walk d450, cook
d630, clean, handle a computer and drive a car
d4751 are reasonable limited. In consultation
with her physician it was mutually agreed to wait
till the problems are reduced before she can
return to her old full-time fixed-hours job. She
is on sick leave, since she can not hold down her
job d850.4 as a secretary and the workplace
policies e5902.3 does not allow her for flexible
work hours, and to work from home.
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Foundations of the ICF

• International
• Independent of health condition / etiology
• Independent of (health) profession

78
International
79
Indepentent of etiology
ICD - 10 S 83.3 Tear of articular cartilage
of knee
80
ICD - 10 S 83.3 Tear of articular cartilage
of knee
81
Indepentent of etiology
Roy Horn after having been attacked by a lyon
Michael J. Fox mit Morbus Parkinson
82
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Indepentent of (health) profession
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"To be useful, practical ICF based tools need to
be tailored to the need of the the users without
forgoing the information needed for health
statistics and health reporting Üstün B et.al.
Common yet specific tools to measure clinical
outcomes ICF Comprehensive Sets and ICF Core
Sets. J Rehab Med 2004 (44 suppl)7-8.
Dr. Bedirhan Üstün WHO Classification Office
Director
86
Development of ICF Core SetsInstitute for
Health and Rehabilitation SciencesICF Research
Branch, WHO CC FIC GermanyLudwig-Maximilian
UniversityMunich, GermanyWHOCAS
Classification, Assessment Surveys
Partner-Organisations
87
Development of ICF Core SetsInstitute for
Health and Rehabilitation SciencesICF Research
Branch, WHO CC FIC GermanyLudwig-Maximilian
UniversityMunich, GermanyWHOCAS
Classification, Assessment Surveys
Partner-Organisations
88
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OA - Body Functions

• b280 Sensation of pain
• b710 Mobility of joint functions
• b730 Muscle power functions
• b770 Gait pattern functions
• b715 Stability of joint functions
• b740 Muscle endurance functions
• b780 Sensations related to muscles and
  movement functions
• b760 Control of voluntary movement functions
• b134 Sleep functions
• b735 Muscle tone functions

91
OA - Body Structures

• s750 Structure of lower extremity
• s730 Structure of upper extremity
• s770 Additional musculoskeletal
  structures related to movement
• s740 Structure of pelvic region
• s720 Structure of shoulder region

92
OA - Activity Participation

• d450 Walking
• d540 Dressing
• d445 Hand and arm use
• d510 Washing oneself
• d470 Using transportation
• d530 Toileting
• d430 Lifting and carrying objects
• d640 Doing housework
• d910 Community Life
• d440 Fine hand use
• d410 Changing basic body position

93
OA - Environmental Factors

• e115 Products and technology for personal use in
  daily living
• e310 Immediate family
• e580 Health services, systems and policies
• e150 Design, construction and building products
  and technology of buildings for public use
• e355 Health professionals
• e540 Transportation services, systems and
  policies
• e120 Products and technology for personal indoor
  and outdoor mobility and transportation
• e135 Products and technology for employment
• e155 Design, construction and building products
  and technology of buildings for private use
• e340 Personal care providers and personal
  assistants

94
Health Conditions

• Chronic widespread pain
• Low back pain
• Osteoarthritis
• Osteoporosis
• Rheumatoid arthritis
• Chronic ischemic heart disease
• Diabetes
• Obesity
• Obstructive pulmonary diseases
• Depression
• Breast cancer
• Stroke

95
ICF CORE SETS FOR CHRONIC CONDITIONS

• Volume 36, Supplement 44 / August 2004

96
Current Developments1st Step Protocol Paper!

• Scleroderma Vienna - EUSTAR, EULAR
• SLE Vienna - EULAR, OMERACT
• Psoriasis Arthritis Wellington - GRAPPA.
  EULAR, OMERACT
• Ankylosing Spondylitis Maastricht - ASAS,
  EULAR, OMERACT
• Spinal Cord Injury Nottwil - ISCoS
• Sleep Helsinki - WASM
• Multiple Sclerosis Valens - MSIF
• Oropharyngeal Cancer Munich - tbd
• Bipolar disorders Barcelona - ISBD
• Vision Munich - ISLRR
• Migraine/Headache Milan - tbd
• Manual Medicine Zurich - SAMM

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Organ-system approach
99
ICF CORE SETS FORTHE ACUTE EARLY POST-ACUTE
SITUATION

• Volume 27, Special issue 7/8April 2005

100
Overview

• The WHO model of functioning and disability
• International Classification of Functioning,
  Disability and Health (ICF)
• ICF Core Sets
• Practical application of the ICF andthe ICF Core
  Sets

101
Development of ICF Core SetsInstitute for
Health and Rehabilitation SciencesICF Research
Branch, WHO CC FIC GermanyLudwig-Maximilian
UniversityMunich, GermanyWHOCAS
Classification, Assessment Surveys
Partner-Organisations
102
Development

• Evidence
• Consensus process

103
Phase I
Phase II
Preliminary Studies

• Consensus
• conferences
• ?
• 1st version of the
• ICF Core Sets

Testing and validation of the 1st version of
the ICF Core Sets
Patients data Multicentric study (ICF based data
collection)
Expert opinion Expert Survey
Study outcomes Literature reviews
3 Years
104
Aims

• ICF categories that are not relevant
• ICF categories that are still missing
• differences among different world regions
• subsets of patients with the same health condition

105
Phase II ValidationComprehensive ICF Core Sets
Quantitative Methodology
Qualitative Methodology
Delphi Methodology
Multicenter international Studie
Health Professionals perspective
Patients perspective
106
WHO Conference 2008
Approval of the ICF Core Sets ICF Research
Branch WHO Genf Partner-Organisations
107
Value of ICF Core Sets

• Define "What to measure"
• and not
• "How to measure"

108
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109
Value of ICF Core Sets

• Define "What to measure"
• and not
• "How to measure"
• Agreement neither possible nor useful
• Appropriate instrument depends on purpose and
  user
• There will always be many measurement options
• Refinements and modifications
• Emerging new instruments

110
Value of ICF Core Sets

• Guide for clinical assessment
• Minimum Functioning catalogue What to assess
• What are the patients problems(we do not have a
  score, we have a list of problems)
• Health statistics
• Complement ICD
• Used by all health professions
• Basis to improve communication
• Among professionals
• Between settings

111
Actual Situation ...
112
Actual Situation ...
Patient
113
Aim and vision ...
ICF-10
Patient
ICF ____________ ____________ ____________
OT documentation ____________ ____________ _______
_____
PT documentation ____________ ____________ _______
_____
114
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117

• Exercise
• Mrs. Baker

118

• Exercise
• Mrs. Backer

119
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120

• Exercise
• Mrs. Backer