INDIANAPOLIS — The Canadian Occupational Performance Measure provides the means to set goals for hand therapy patients based on their individual life stories and occupational needs, rather than standardized measures, which is the same way patients themselves gauge the success of their therapy, according to two occupational therapists from Rancho Los Amigos National Rehabilitation Center just outside Los Angeles.

"It measures outcome from the client’s perspective, which makes it really unique and different from some of the other outcome tools," said Michele Berro, OTR/L, MA, clinical manager.

Standard measures

Common outcome measures are questionnaires with predetermined sets of questions, said Lisa Deshaies, OTR/L, CHT, clinical specialist. One of the most common is the Disabilities of the Arm, Shoulder and Hand, which has 21 questions. It has been modified into a six-question version called the Quick DASH. There is a newer Manual Ability Measure, which has about 20 questions. There’s the Michigan Hand Outcomes Questionnaire, which has 72 questions, so it’s a little more extensive, she said. And it grades both hands. There’s also Patient Rated Hand/Wrist Evaluation, Upper Extremity Functional Index and Upper Limb Function Index, she added.

"So there are a lot of different ways to capture outcomes with hand therapy patients," Deshaies said. "All of these are great questionnaires, which do give you a quantifiable outcome from therapy."

But even though functional outcome measures, such as DASH, MAM, MHQ, PRWHE, UEFI and ULFI, can be used to compare clients to one another, they lack individual focus, Deshaies said. "If you just stick with hand function tests, it’s not a good reflection of what somebody is doing at home," she said. "Performance and hand function tests fall short of measuring activity levels in daily life."

The research

Studies have shown that patient satisfaction is not tied directly to objective clinical changes, but there is a trend toward greater satisfaction with increased function, Deshaies said.

An article, "Adaptation to Hand Injury: An Evolving Experience," by Josephine Chan, OTR, PhD, CHT, and Jean Spencer, OTR, PhD, FAOTA, which ran in the American Journal of Occupational Therapy in March/April 2004, followed five participants’ recoveries from acute hand injuries over 12 months to study similarities and differences in physical recovery, psychosocial adaptation, engagement in occupations and relationships, perceived outcomes, expectations and adaptive strategies.

"The good news is the findings really validated the support of occupation-based therapy, and also heightened the importance of connecting the rehabilitation experience to the client’s daily life and to the motivating occupations and relationships important to them," Deshaies said. "Another interesting component is they recognized the process of developing hope for the future was discovered by the clients through experience and actually doing things."

Jane Case-Smith, OT/L, EdD, had a study published in the same journal in September/October 2003, "Outcomes in Hand Rehabilitation Using Occupational Therapy Services," in which she submitted 33 participants with upper extremity injuries to the COPM, DASH and Short Form 36. "She found of those three measures, the COPM was actually the most sensitive to client change" Deshaies said. OTs in the study reported the COPM helped focus intervention and supported development of measurable and achievable goals that were meaningful to the clients.

"When the COPM was developed, it was shown to be valuable and reliable across all diagnostic groups and across all [developmental] stages, " Deshaies said.

"Hand therapy really isn’t a discipline unto itself," Deshaies said. "So one of the things that’s a really big challenge when you’re dealing with hand patients is trying to maintain your core values as an OT while you’re dealing with a very medical model type of system. ... The COPM has been one great way at Rancho Los Amigos National Rehabilitation Center for us to respect [OT values]."

Three-step evaluation

Client-centered practice "is really knowledge of the client’s priorities, values and beliefs. It’s collaboration on mutually agreed-upon goals. It’s active client participation in the decision-making process. And it’s a focus on client-perceived outcomes," Berro said. "So how can we redefine practice to be client-centered and occupation-based?"

There are three types of therapeutic interventions: preparatory, purposeful and occupation-based, Berro said. "Is there a place for all of these in OT practice? Absolutely. We’re looking to balance them."

Rancho Los Amigos uses a three-pronged evaluation: an occupational profile, a typical day description and the COPM.

The occupational profile uses "open-ended questions that get the patient or client talking, then you can continue probing from there," Berro said.

The typical day description is done on a graph with times of the day running down the left-hand column. The patient provides detailed descriptions of daily activities, routines and context.

Then the COPM "is conducted in a semi-structured interview format where we are able to identify a problem in occupational performance in self care, productivity and leisure," Berro said. The patient chooses his or her top five occupational goals, then rates on a scale of 1-10 importance, current performance of the task and current satisfaction with performance.

This tells the OT how to prioritize treatment. And upon discharge, each goal is rated again in terms of performance and satisfaction. "A change score of 2 or more is considered clinically significant," Berro said.

In a summary of 1,097 COPMs submitted by Rancho Los Amigos between 2007 and 2010, the mean improvement in performance was 3.43 points and in satisfaction was 3.71 points. Age, gender, language and ethnicity did not have a significant effect on change scores, Berro said.

Unique life stories

"Our patients are very different. Their stories are very different. Their goals are very different," Berro said.

For example, two young (18 and 22) male students who were victims of gunshot wounds to the upper extremity chose different top five goals. The 18-year-old wanted to hold his video game controller, hold a steering wheel, write neatly, put his socks on and tie his shoes. The 22-year-old wanted to wash his other arm, fasten his pants, open containers, cut his fingernails and use a computer keyboard. "You would think those two very similar in age, race, diagnosis and life stage would want to do the same things, but actually they were quite different," Berro said. •

Natasha Emmons is editor of Today in OT.