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Rehabilitation Research provided the new paradigm of disability that focused attention on the imperative of environmental modifications to improve the lives of people with disabilities.4 The Institute of Medicine’s (IOM’s) book Enabling America5 promoted the importance of environmental factors for people with disabilities. Researchers focused their attention on the development of participation and environmental measures, including the Craig Handicap Assessment and Reporting Technique,6,7 the Community Integration Questionnaire,8 and the Craig Hospital Inventory of Environmental Factors.9,10

Although the models theoretically incorporated the importance of environmental factors, little empirical evidence exists to support the theory. For example, spinal cord injury (SCI)-related research has linked impairment and disability to participation. Although the severity of the impairment had a strong relationship with the performance of activities of daily living, the research found no strong links between impairment or disability measures and participation.11,12 A meta-analysis conducted by Dijkers13 concluded that participation was more strongly related to quality of life than to either impairment or disability.


Society’s and researchers’ conceptualizations of disability have evolved over time. As noted in Enabling America5 and on the basis of public policy at the time, “In the 1950s, impairment of a given severity was viewed as sufficient to result in disability in all circumstances; in contrast, the absence of impairment of that severity was thought to be sufficient grounds to deny disability benefits” (p. 63) Although the practice of rehabilitation certainly existed before then, it was not until the 1960s and the 1970s that conceptual frameworks for modeling disability appeared. These conceptual frameworks allowed greater scientific inquiry into both disability and rehabilitation.

In 1972, WHO, recognizing a need for better methods to evaluate health care, sought to expand the medical model of illness that provided the basis for its International Classification of Disease (ICD).14 WHO recognized that ICD14 suited the study of the outcomes of acute diseases and injuries that can be prevented or cured but that the medical model did a woefully inefficient job of detecting the consequences of nonacute diseases, particularly chronic and progressive or irreversible disorders. In 1980, WHO published ICIDH1 as “a manual of classification relating to the consequences of disease.” It extended the disease-related sequence of etiology, pathology, and manifestation with the illness-related sequence of disease, impairment, disability, and handicap. Although the original ICIDH model acknowledges a role of the environment by stating that “handicaps thus reflect interaction with and adaptation to the individual’s

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