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

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. 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. 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.