- Top of page
- PATIENTS AND METHODS
In the last decades there has been a change in the health care system, with an increased emphasis on client participation in the treatment or rehabilitation process. Improved occupational performance and community participation have also, to a larger extent, become important goals and outcomes of rehabilitation (1, 2). Patients with rheumatic diseases usually experience limitations in performing activities of daily living. The kind of occupational performance problems the individual will experience is to a large degree influenced by the patient's disease, personality, age, social situation, and the physical and cultural context (3). Intervention should be directed toward the problems that the patients regard as most important. Thus, there is a need to develop tools that describe the patients' problems within a wide range of occupations, to know which of these problems cause greatest concerns to patients, and to measure how they experience and rate their performance of these activities.
In the field of rheumatology, the issue of including the patient perspective in clinical practice and research has been discussed for some years, and was one of the main topics of the Outcome Measures in Rheumatology Clinical Trials (OMERACT) conference in 2000 (4). To date, rheumatic patients' preferences in activities of daily living have been addressed in a few outcome measures; e.g., the McMaster Toronto Patients Preference Disability Questionnaire (5), and the Problem Elicitation Technique (6).
The Canadian Occupational Performance Measure (COPM) (7) is a generic and individualized measure designed to detect changes in patients' self perception of occupational performance and satisfaction with performance over time. The assessment is theoretically based on the Canadian Model of Occupational Performance, in which occupational performance is defined as, “consisting of self-care, productivity, and leisure; being influenced by the environment, one's social roles and one's developmental level; being client-defined; and consisting of both a performance (objective) dimension and a satisfaction (subjective) dimension” (8).
COPM is currently used in >25 countries in the world and has been translated to many languages, including Icelandic, Danish, and Swedish. The psychometric properties of the instrument have been established in some groups of patients, including patients with chronic pain (9) and disabled individuals living in the community (8). In a recent study, construct validity was tested by comparing COPM performance scores with Health Assessment Questionnaire (HAQ) scores in a group of patients with rheumatoid arthritis (10). The results showed a significant correlation between the COPM scores and the HAQ scores for similar activities.
The COPM manual reports that the intraclass correlation coefficients for test-retest reliability of performance and satisfaction scales range from 0.75 to 0.89 in a mixed group of patients, and concludes that COPM is a reliable measure (7). COPM has also revealed high responsiveness for measuring change in occupational performance (9, 11, 12).
Several studies of feasibility report that patients and therapists in general find the administration of COPM easy, and that the process seems to identify a wide range of occupational performance problems. It may serve as a basis for the process of establishing targeted outcomes, planning further intervention, and evaluating the effect of treatment or rehabilitation (8, 9, 12–14).
The COPM was recently translated to Norwegian (15). The OMERACT filter for outcome measures in rheumatology recommends that all outcome measures should be evaluated according to the criteria of truth, discrimination, and feasibility (16). In this study, the psychometric properties of the Norwegian version of the COPM were tested for validity, responsiveness, and feasibility in a group of patients with hand osteoarthritis.
- Top of page
- PATIENTS AND METHODS
This study highlights that COPM is a highly responsive instrument for measuring changes in function. The individual design of the instrument is probably the main reason for this, giving significant information about which occupational performance problems the patient experiences as most important to address in intervention, thereby assuring that a change is likely to be noticed. In this way, the COPM also provides information that is complementary to other health measures frequently used in clinical research.
In general, the results confirm the validity of the COPM in patients with hand osteoarthritis. The distribution of problems in the 9 categories in COPM corresponds with results from a study by Yelin et al (28), who found that patients with osteoarthritis experienced most losses in performance of household chores, shopping and errands, and leisure, and that they also spent more time than healthy persons in personal care and hygiene. The great variability in the activities described indicates that COPM identifies a wide range of occupational performance problems within different areas. The low number of described problems in the categories work and play/school is probably explained by age, and the fact that only 29% of the patients were still working.
Criterion validity was supported by a high correspondence between patient's preferences for improvement in health in AIMS2 and the prioritized problems in COPM, and also by the parallel in the areas not prioritized, namely work and social activities or socialization. As expected, there were low correlations between the scores from MHAQ, AUSCAN, and WOMAC and the COPM scores, indicating that COPM measures function from a different aspect.
The testing of construct validity supports the hypothesis that disease activity is one important factor determining occupational performance and satisfaction with performance. However, the relatively low correlation also point to the fact that occupational performance is a complex phenomenon, with many factors contributing to the process and experience. Some of these may be the varying complexity of different activities, the working technique used by the individual, and the context in which the activity takes place. Future studies should investigate these associations to increase our knowledge of which factors to address in treatment and rehabilitation.
In the present study, there were significant positive changes in both the performance and the satisfaction scores in COPM. The greater change in satisfaction score than in performance score is similar to findings from other COPM studies (29) and suggests that, for example, changed attitudes and adjusted expectations to performance of various tasks may have increased the patients' satisfaction, even if the performance remained unchanged. A limitation to the study is that the COPM interview and the following intervention were carried out by the same therapist. Some of the improvement demonstrated may therefore be explained as an eager to please effect. However, the variations in scores between the patients and within the activities prioritized by each patient indicate that this is not the only reason, because an eager to please effect would be expected to be distributed more evenly among the patients and activities.
Beaton et al (30) describe how an experience of being better may not only reflect a change in the state of the patient's disorder, but also an adjustment in life, an adaptation to living with the disorder, or a combination of any of these. They suggest that outcome measures should allow patients to generate their own item content to express how the disorder has affected them. The individual design of the COPM ensures these recommendations, thereby promoting responsiveness. When comparing SRM across different instruments, COPM satisfaction is clearly the most sensitive score, followed by COPM performance and MHAQ.
Studies of persons with rheumatoid arthritis have shown that declines in the ability to engage in valued activities significantly increase the risk of developing depression (31) and that satisfaction with abilities seems to mediate the relationship between occupational performance and an increase in depressive symptoms (32). To be able to address this in care, it is important to assess not only functional decline, but also which activities are most valued by the individual and how the limitations are experienced. Interestingly, both an early version of MHAQ (18) and the revised AIMS2 (19) include satisfaction with function as a dimension of health, but the use of these satisfaction measures has been limited (4). However, the results from the present study imply that measuring satisfaction provides sensitive, valid, and clinically important information.
Regarding feasibility, the patients' responses to the COPM interview in general were positive, indicating that the process of describing and prioritizing activity problems provides a good basis for further planning and intervention. However, 37% of the patients experienced the scoring procedure as difficult, a problem also recognized in other studies (8, 29, 33). The fluctuating state of osteoarthritis was one reason given for this, a problem that probably is common for most patients with rheumatic diseases regarding numerical scoring of health status and functional problems. The 10-point COPM rating scale may have increased these problems because it presents a relatively high number of scoring options. A reduction to, e.g., a 5-point scale could be an alternative that merits testing and validation. The age of the patients may have contributed to the scoring problems because difficulties with numeric scoring procedures are known to increase with age (34, 35). Elderly people with long experience from a health care system based on a traditional medical model may also expect the health professional as the expert to be the one who should decide which problems require intervention. The patients' concerns about being perceived as complainers and some of their difficulties in the numeric scoring could be understood as anxiousness of giving wrong answers and may reflect challenges connected to the role as an active participant in the treatment process. Further testing of COPM in younger patients and in patients with other rheumatic diseases may help clarify these aspects.
In summary, the results indicate that COPM is a valid and responsive instrument for use in clinical practice with patients with hand osteoarthritis. Although the scoring process was somewhat difficult for some of the patients, the study also confirms the clinical feasibility of the COPM in the process of goal setting, planning, and monitoring intervention. The COPM may therefore serve both as an outcome measurement and as an instrument to promote a client-centerd approach in various clinical settings.