COPM for Older Adults with Hip Fractures: Outcomes Guide

Introduction

This paper provides an analysis and recommendation for measuring occupational performance outcomes via the Canadian Occupational Performance Measure (COPM) within the geriatric demographic of patients who suffer from hip fractures. Specifically, it examines the hip fracture case of a 73-year-old female injured in an accident at home. The performance measurement is defined by the rate of therapeutic success associated with her ability to perform activities of daily living (ADLs), which include bathtub entry and exit, fitting and removing footwear, tying footwear, sewing, gardening, and cooking and serving both hot and cold meals.

Occupational performance requires understanding the patient's specific physical ability and mental stamina, and addressing the need to stimulate both in order to promote a speedy and full recuperation. Current research on the physical therapy process for hip fracture patients provides comprehensive information describing the COPM, which includes areas for self-care, productivity, and leisure (Law, Baptiste, Opzoomer, Polatajko, & Pollock, Vol. 57, No. 2).

A conceptual comparison is further established with the occupational performance measurement of patients suffering from traumatic brain injury, including stroke (Phipps & Richardson, 2007). The rate of performance improvement is examined as a function of the marginal time required to reach full convalescence for each trauma type.

The purpose of this case report is to determine the optimal path to occupational performance outcome measurement success for this patient and her patient type. The physical therapy process for geriatric patients differs substantially from that undertaken with younger populations. Geriatric patients have different nutritional needs and are less able to build muscle mass or absorb the calcium levels necessary to strengthen bone structure. The plan addresses these issues and recommends the most appropriate physical therapy program to restore optimal functional ability equivalent to that of an otherwise healthy 73-year-old female.

According to Cree (1998), "The term hip fracture is a generic term referring to a number of different types of fracture of the femur. The primary classification of hip fractures divides those within the capsule of the hip joint (intracapsular) from those outside it (extracapsular)" (Parker and Pryor). While extracapsular fractures tend to heal well, prognosis is poor for intracapsular fractures (Cree, 1998).

Literature Review

Research from patients monitored in Ontario indicates that a hip therapy rehabilitation waiting time exceeding six months can have detrimental effects on performance outcomes. According to Cipriano, Chesworth, Anderson, and Zaric (2007), "Currently, the median waiting time for total hip and knee replacement in Ontario is greater than 6 months. Waiting longer than 6 months is not recommended and may result in lower post-operative benefits."

Pain management is also critical during the post-operative rehabilitation process, when the patient is regaining strength in the hip bone, joint, and surrounding muscle region. Management of pain is necessary for the patient to perform activities such as ambulating in and out of the bathtub and operating a vacuum during housekeeping. According to Hallstrom (2001), "patients with hip fractures are in pain. From the patients' point of view, pain is something that is related to illness and surgery, and they rarely complain about inadequate pain medication (Patterson et al., 1992)."

The Canadian Association of Occupational Therapists holds that the patient is primary to the success of the occupational therapy program. The occupational performance model (Law et al., Vol. 57, No. 2) is established on a set of beliefs that position the individual as the focal and core component of the therapeutic process. According to Law et al., an individual's occupational performance is understood as "a balance between performance in three areas: self-care, productivity and leisure (DNHW & CAOT, 1983)."

A task force used the occupational performance model as a basis to investigate existing outcome measures of self-care, productivity, and leisure. The task force reported that no measure was available to adequately evaluate occupational performance as described by the Guidelines for the Client-Centred Practice of Occupational Therapy (DNHW & CAOT, 1987). The task force further identified the following beliefs as central to occupational therapy practice: that the individual client is an essential part of occupational therapy practice; that the client should be treated holistically; that activity analysis and adaptation may be used to effect change in the individual client's performance; that the client's developmental stage is an important consideration; and that role expectations must be taken into account when assessing a client's performance (Law et al., Vol. 57, No. 2).

The National Health and Welfare and Canadian Association of Occupational Therapists Task Force's focus on the occupational performance model reflects a strategic belief in the individual's ability to lead a balanced life based on self-care, productivity, and leisure. The task force also emphasizes more holistic aspects of the patient's physical, emotional, and spiritual condition as means toward expeditious occupational therapy outcome success.

Patients undergoing rehabilitation using the COPM work with their occupational therapist, who facilitates the ranking process. Sessions are aimed at establishing the range of motion needed to conduct various activities, which in turn develops the neural network and motor skills to perform ADLs. According to Case-Smith (2003), "examples of goals selected by the participants are driving, typing, writing, cooking, child care, doing laundry, using tools, gardening activities that involved lifting heavy objects, specific work tasks (hair dressing, teaching), and a wide variety of leisure activities."

According to Law et al., "The individual's mental, physical, socio-cultural and spiritual characteristics, as well as environmental factors, have a great influence on achievement of this balance. Occupational therapy based on this model involves the assessment of the abilities and disabilities of the individual client within his/her environment and role expectations. Together the client and the therapist determine therapeutic goals, implement treatment, and assess the outcome of treatment" (Vol. 57, No. 2).

The administration and scoring of the COPM models occupational performance outcomes and successes for self-care, productivity, and leisure, encompassing process assessment and evaluation of range of motion and flexibility. The advantage of this method is that therapy is individualized based on physiological response — while not diagnosis-specific — yet is specific to the patient's goals and the outcomes of therapy in relation to the successes in meeting each goal collectively (Law et al., Vol. 57, No. 2).

Self-care encompasses personal care (dressing, bathing, and feeding), functional mobility (stairs, bed, and cars), and community management (transportation, finances, and services). The COPM uses a five-step process built around a semi-structured interview conducted between the therapist and patient: (1) problem definition, (2) problem weighting, (3) scoring, (4) reassessment, and (5) follow-up (Law et al., Vol. 57, No. 2).

According to Kuijer, de Beer, Houdijk, and Frings-Dresen (2009), "It is quite normal to assume that, if joint function improves, people can resume their normal lives, including their work. However, this may not always be the case. It could be that, despite nearly normal range of motion, working activities remain difficult to perform for a certain period of time." It is therefore important to continuously work through the motions of housekeeping activities that require hip and joint movements, such as vacuuming and the bending associated with bathtub cleaning.

The rehabilitation process allows the patient to transition from requiring assistance — whether human or assistive-device — to performing the same occupations unassisted. According to the Center for Patient and Community Education (2009), precautions necessary to avoid further hip damage when putting on and tying shoes include: "Do not bend your fractured hip beyond a 90-degree angle. Do not turn your operated leg inward in a pigeon-toed position. Do not cross your operated leg. Avoid bending forward when putting on socks and shoes. Keep your back touching the back of the chair. Use elastic shoelaces or slip-on shoes."

The precautions for ambulating into and out of the bathtub, according to the Center for Patient and Community Education (2009), include: "Place a non-skid rubber bath mat on the floor of the stall or tub; ensure the suction cups are pressed down prior to turning the faucet on. Do not sit on the bottom of the tub — this causes too much bending of the hip. Use liquid soap to avoid dropping a bar of soap. A long-handled bath sponge will help in bathing below the knees."

Post-operative housekeeping precautions, also from the Center for Patient and Community Education (2009), include: "Sit for rest breaks as needed. Slide objects along the countertop rather than carrying them. Use a utility cart with wheels to transfer items to and from the table. Attach a bag or basket to your walker, or wear a fanny pack to carry small items. Use a long-handled reacher to reach objects on the floor. Remove all throw rugs and long electrical cords to avoid tripping. Watch out for slippery or wet areas on the floor."

Problem definition involves the occupational therapist conducting a patient interview to verify any problems in occupational performance. The functionality of this approach is client-side identification of need, including whether there is an inability to perform a physical activity. If a difficulty is reported, the performance area is identified as a problem and addressed in accordance with the patient's wishes. According to Simmons, Crepeau, and White (2000), "The essence of client-centered care in occupational therapy is setting goals that are individually relevant (Law, 1998; Townsend, 1997). To do so, therapists must collaborate with clients and understand their priorities."

Problem weighting uses a Likert scale (1–10) with the client ranking their performance and satisfaction for each activity. Scoring is based on the importance rating from the previous step. According to Law et al., "the five most urgent problems are identified. The client is then asked to rate his ability to perform these specified activities and his satisfaction with that performance using the same 1–10 scale. The ratings of ability and satisfaction are then each multiplied by the importance rating to determine baseline scores. The possible range of scores is from 1 to 100 for satisfaction and 1 to 100 for performance for each of the problems identified" (Vol. 57, No. 2).

Reassessment and follow-up require the patient to re-evaluate his or her performance and satisfaction ratings in accordance with the problems identified in Step 1. Ratings are multiplied by the original importance ratings, then totaled and divided to determine the change in client performance over time. This provides a means to measure change as a function of the therapeutic process. Follow-up determines whether discharge is appropriate, using a COPM form in which the therapist revisits six questions from Step 1 to ascertain whether occupational performance problems remain (Law et al., Vol. 57, No. 2).

Occupational therapy outcomes for clients with traumatic brain injury and stroke, as examined by Phipps and Richardson (2007) using the COPM, utilize client-identified performance goals to guide occupational therapy treatments and to measure clinical outcomes (Baum & Law, 1997; Law et al., 2005). The instrumentation is grounded in client-specific goals, assessing changes in client-perceived performance and satisfaction as determined by occupational performance over time (Pollock, 1993).

According to Phipps and Richardson (2007), "These studies used client-identified goals to guide occupational therapy intervention based on the specific needs of the clients. Therefore, each occupational therapy program was unique and based on the goals identified by the client and the family rather than the therapist. The COPM is a practical assessment that can be incorporated into the initial evaluation and improves efficiencies throughout the treatment program for the therapist by focusing on the client's primary goals."

The COPM was administered to participants both at the commencement and at the discharge of the occupational therapy program (Phipps & Richardson, 2007). As in other studies, the semi-structured interview approach asked patients "to describe a typical day in order to document their daily routines and participation in occupations before the onset of disability and after the onset of disability."

Patients — also referred to as participants — rank each occupational performance problem identified across self-care, productivity, and leisure. Each patient then identifies and ranks the urgency of specific activities assessed as areas requiring additional work or ambulatory practice within the outpatient occupational therapy program, based on the performance goals identified as important through the COPM (Phipps & Richardson, 2007).

HIPAA regulations prevent the identification of the individual receiving treatment as well as the release of medical information that includes identifying details. The 73-year-old female suffered a fractured hip as the result of an accident inside her home. She is independent of spirit and wishes to remain active — specifically, to perform her ADLs unassisted. This goal encompasses bathtub entry and exit, putting on and tying her shoes, and preparing a meal from start to finish including clean-up, as measured through the occupational performance outcomes of the COPM.

The COPM aligns closely with the task force's assertion that self-care, productivity, and leisure are primary to program success. These measures provide the most optimal means to identify the change in progress from entry to exit and to operationalize performance measurement constructs through the semi-structured interview process.

Introducing the Patient

Therefore, the best measures are a function of the symbiotic relationship among the literature review cases, which collectively point to the five-step approach and its scoring criteria as the most appropriate method for creating a client-specific occupational therapy rehabilitation program. The methodology encompasses problem definition, problem weighting, scoring, reassessment, and follow-up.

The intervention methodology follows directly from the literature review and the best measures identified above. The case of the 73-year-old female geriatric patient — who suffers from a fractured hip and is committed to performing to her full capable capacity — falls within the parameters defined by those best measures.

The problem definition addresses hip flexor range of motion and the ability to pronate, supinate, and rotate in order to perform ADL-related activities. Additionally, the intervention seeks to ensure sufficient bone strength to prevent further fracture or breakage should the patient fall directly onto the site of the previous injury. The interview process determines the level of therapy needed from a medical perspective, with her developmental progress gauged in part by her own perception of how well her recovery is advancing.

Conclusion

Law, M., Baptiste, S., McColl, M., Opzoomer, A., Polatajko, H., & Pollock, N. The Canadian Occupational Performance Measure: An outcome measure of occupational therapy. CJOT, Vol. 57, No. 2.

Phipps, S., & Richardson, P. (2007). Occupational therapy outcomes for clients with traumatic brain injury and stroke using the Canadian Occupational Performance Measure.

Simmons, D. C., Crepeau, E. B., & White, B. P. (2000). The predictive power of narrative data in occupational therapy evaluation. American Journal of Occupational Therapy, 54, 471–476.