the canadian occupational performance measure: a research and clinical literature review

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DOI: 10.1177/000841740407100406

2004 71: 210Canadian Journal of Occupational TherapyAnne Carswell, Mary Ann McColl, Sue Baptiste, Mary Law, Helene Polatajko and Nancy Pollock

The Canadian Occupational Performance Measure: A Research and Clinical Literature Review

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210 OCTOBRE 2004 ■ REVUE CANADIENNE D’ERGOTHÉRAPIE ■ NUMÉRO 4 ■ VOLUME 71 © CAOT PUBLICATIONS ACE

The Canadian Occupational Performance Measure: A research and

clinical literature review

Key words ■ Occupational therapy assessment ■ Literature review ■ Canadian Occupational Performance Measure (COPM)

RésuméDescription. Il y a déjà 13 ans que la Mesure canadienne du rendement occupationnel (MCRO) a été publiée. Depuis ce temps,la MCRO est de plus en plus reconnue et acceptée à titre de mesure des résultats dans les milieux cliniques et de recherche energothérapie. But. Le but de cet article est de présenter une revue des études scientifiques et cliniques effectuées depuis 1994 etde documenter leurs effets sur la pratique et la recherche en ergothérapie, à travers le monde. Méthodologie. Une recherche systématique des études cliniques et scientifiques a été effectuée dans les publications en anglais (principalement axées sur l’ergothérapie). Quatre-vingt-huit études répondant aux critères d’inclusion ont été examinées. 86 % de ces études examinaientla MCRO en fonction de ses propriétés psychométriques (19 articles), des résultats de recherche (33 articles) ou de la pratique (33articles). Résultats. Dans l’ensemble, bien qu’il existe certaines limites, qui sont discutées dans la présente analyse, la conclusionde cette étude est que la MCRO est une mesure des résultats valide, fiable, adaptable et cliniquement utile, qui est acceptable pourles cliniciens et les chercheurs en ergothérapie. Conséquences pour la pratique. La MCRO est utilisée auprès de diverses clientèles; elle favorise la pratique centrée sur le client, facilite la pratique fondée sur les données probantes et soutient larecherche fondée sur les résultats.

Anne Carswell ■ Mary Ann McColl ■ Sue Baptiste ■ Mary Law ■ Helene Polatajko ■ Nancy Pollock

AbstractBackround. It has been 13 years since the Canadian Occupational Performance Measure (COPM) was published. In that time there has

been a remarkable growth in its acceptance as an outcome measure within the occupational therapy practice and research. Purpose.

The purpose of this paper is to review the emerging research and clinical literature related to the COPM since 1994 and to document its

impact upon occupational therapy practice and research throughout the world. Method. A systematic search was conducted to the

professional and research literature in English publications (primarily occupational therapy). Eighty-eight papers that met the inclusion

criteria were reviewed, 86% of which examined the COPM in relation to its psychometric properties (19 papers), research outcomes (33

papers) or practice (33 papers). Results. Overall, although there are a few limitations discussed in the review, the conclusion is that the

COPM is a valid, reliable, clinically useful and responsive outcome measure acceptable for occupational therapist practitioners and

researchers.Practice Implications.The COPM is used with a wide variety of clients, enables client-centred practice, facilitates evidence-

based practice and supports outcomes research.

been conducted to date and published primarily in majoroccupational therapy sources. Therefore, the purpose of thispaper is to review the emerging literature on the COPM, andto document the impact of the COPM upon occupationaltherapy research and practice.

The initial research supporting the COPM was largelyconducted by the authors (Law et al., 1990; Law, Polatajko etal., 1994; Pollock et al., 1990; Toomey, Nicholson & Carswell,1995). These initial articles were aimed at demonstrating themeasurement properties of the COPM and assuring an occu-pational therapy readership that this measure was supportedby empirical substance. In recent years, there has been amarked increase in publications involving the COPM from a

It has now been 13 years since the Canadian OccupationalPerformance Measure (COPM) was originally published. Inthat time, it has seen remarkable growth in acceptance and

popularity. Since its initial publication in 1991, the COPM hashad two subsequent editions published and has been officiallytranslated into 20 languages. It is in use by occupational therapists in over 35 countries throughout the world.

One of the most frequently asked questions to theauthors and to the publisher is a question regarding whatresearch has been done or is being done on the COPM. Ofcourse, it is impossible for us to track this activity, but wethought on this thirteenth anniversary of the publication ofthe COPM, it would be timely to review the research that has

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CARSWELL ET AL.

variety of sources. An increasingly large body ofliterature attests to the clinical utility and measurement properties of the COPM. A further body of literature acceptsthese qualities at the outset, and uses the COPM as an out-come measure, to assert the value of occupational therapyservices or the efficacy of particular interventions.

The therapist who uses the COPM begins with a semi-structured interview to ask clients to identify issues in areasof self-care, productivity and leisure. Once clients have identified their problems, they rate their perceptions of theimportance of each activity on a scale from 1 to 10. From thislist, clients choose up to five problems they wish to focus onduring occupational therapy. For each of the problems,clients then rate performance and satisfaction with perfor-mance, again using a scale from 1 to 10. Higher ratings indi-cate greater importance, performance and satisfaction. Theperformance and satisfaction scores of the selected activitiesare summed and averaged over the number of problems, toproduce scores out of 10.

The COPM is completed as an initial assessment andoccupational therapy objectives are based upon these selectedproblems. After a negotiated period of occupational therapyintervention, clients again rate their performance and satisfaction on the same activities, which are summed andaveraged. The difference between the initial and subsequentscores (change score) indicates an outcome. A change score oftwo or more is considered clinically significant (Law et al.,1991; Law, Baptiste et al., 1994; Law, Baptiste et al., 1998).

At the most basic level, the COPM may be assumed tohave face and content validity, since it overtly addresses itselfto the three dimensions of occupation: self-care, productivityand leisure. McDowell and Newell (1996) suggest that measures of health (including occupation) must have a

conceptual basis against which validity may be assessed. Inthe case of the COPM, this conceptual grounding is theCanadian Model of Occupational Performance, as outlinedin the document Enabling Occupation (CAOT, 2002).

In 2001, Law and Baum posed a series of questions thatan occupational therapist might ask to determine whether ornot a measure would be useful in occupational therapy prac-tice. The questions included the following: what was the purpose of the instrument, was the measure clinically useful,was its construction adequate, and was the measure stan-dardized, reliable, valid and responsive? The constructionand evolution of the COPM was based upon well-reasonedinput from the research literature, practicing occupationaltherapists and real world testing with occupational therapyclients. In spite of a semi-structured interview format,application of the COPM is standardized, and statistics areavailable for clinically significant levels of change and goalattainment (Law et al., 1991; Law, Baptiste et al., 1994; Law,Baptiste et al.,1998). This detailed review will enable occupa-tional therapists to answer the questions posed by Law andBaum (2001).

In this review, we summarize the research that has beenconducted in the twelve years since the initial publication ofthe COPM in 1991. In so doing, we hope to respond to theapparent need to assemble the evidence in support of theCOPM and also a reckoning of the arguments against it.

ObjectiveA systematic review of the published literature was undertakento determine whether the COPM is a psychometrically robustand clinically useful outcome measure in occupational therapy.The results will be discussed in terms of the COPM’s impact onclient-centred, evidence-based occupational therapy.

VOLUME 71 ■ NUMBER 4 ■ CANADIAN JOURNAL OF OCCUPATIONAL THERAPY ■ OCTOBER 2004 211© CAOT PUBLICATIONS ACE

TABLE 1Journals used in the review.

Activities, Adaptation and AgingAmerican Journal of Alzheimer’s DiseaseAmerican Journal of Occupational TherapyArthritis and RheumatismAssistive Devices Outcomes Australian Occupational Therapy JournalBritish Journal of Occupational TherapyBritish Journal of Therapy and RehabilitationCanadian Journal of Occupational TherapyClinical RehabilitationDevelopmental Medicine and Child NeurologyDisability and RehabilitationHaemophiliaHand ClinicsHuman Movement ScienceInternational Journal of Palliative NursingInternational Journal of Rehabilitation Research International Journal of Therapy and Rehabilitation

Journal of Allied HealthJournal of GerontologyJournal of Hand TherapyJournal of Rehabilitation MedicineJournal of Spinal Cord MedicineOccupational Therapy in Mental HealthOccupational Therapy InternationalOccupational Therapy in Journal of ResearchPaediatric Physical TherapyPaediatric RehabilitationPhysical and Occupational Therapy in PediatricsPhysical and Occupational Therapy in GeriatricsPhysiotherapy CanadaRehabilitation and Community Care ManagementScandinavian Journal of Occupational TherapyThoraxWFOT Bulletin



CARSWELL ET AL.

MethodsA systematic search was conducted of the professional andresearch literature in occupational therapy published inEnglish related to the COPM. The review covers the periodfrom January 1991 to July 2003. It was undertaken throughMEDLINE, CINAHL and OTDBase. Table 1 summarizes thejournals covered by the review. A hand search was also completed to find those articles that were not captured in thedatabase search but referenced in a journal article. Inclusioncriteria for the review were as follows. An article was includedif it:

(a) identified the COPM either in the title or abstract and

(b) reported on one of the following attributes of the COPM:

• psychometric attributes

• contribution to research outcomes

• contribution to occupational therapy practice

ResultsThis process resulted in a total of 88 articles published in the12 years of journal issues searched. Of these, 76 (86%) couldbe categorized into one or more of the following three categories:

• psychometric properties of the COPM (19)

• research outcomes (33)

• occupational therapy practice (33)

The remaining articles reflected the initial papers defin-ing the development and initial testing of the measure(Baptiste, 1993; Carswell, 1995; Pollock, 1992), survey orpractice papers (Hammond, 1996; Hanna & Rodger, 2002;Liddle & McKenna, 2000) and theoretical discussions thatconsidered the COPM in light of models of practice or thephilosophy of occupational therapy and evaluation (Hanna& Rodger, 2002; Robertson, 2002;).

Psychometric properties of the COPMNineteen (19) articles were identified that examined the psychometric properties of the COPM: specifically, reliabil-ity, validity and responsiveness (see Table 2).

In addition to the research on the reliability of theCOPM contained in the COPM Manual (Law, Baptiste et al.,1998) a further three quasi-experimental studies tested thereliability of the COPM (Cup, Scholte op Reimer, Thijssen &van Kuyk-Minis, 2003; Sewell & Singh, 2001). The studiesdemonstrated strong test-retest reliability for both the performance and satisfaction scores when tested one weekapart. Cup et al. (2003) reported correlation coefficients 0.89(p<0.001) for performance and 0.88 (p<0.001) for satisfac-tion in the Dutch version of the COPM. Sewell and Singh(2001) reported intra-class coefficients of 0.81 (p<0.001) forperformance and 0.76 (p<0.01) for satisfaction.

Eleven articles examined the validity of the COPM.Concurrent (criterion) and content validity was testedamong a variety of clients (see Table 2) and among occupational therapy practitioners. Generally the studies onvalidity support the COPM as a valid measure of occupa-tional performance. Simmons, Crepeau and White (2000)determined that among adults with sub-acute conditionswhen the COPM was added to the Functional IndependenceMeasure (FIM) the accuracy for occupational therapy out-come prediction was enhanced over using only the FIM.Boyer, Hachey and Mercier (2000) found that occupationalperformance accounted for a small portion of the variance insubjective quality of life. Lewis and Jones (2001) and McColl,Paterson, Davies, Doubt and Law (2000) reported that theCOPM was a valid measure of client-perceived performanceand satisfaction. Using measures of quality of life and func-tional performance, they showed that COPM scores corre-lated in expected patterns with scores on other well-knownmeasures. Chan and Lee (1997) challenged the validity of theCOPM by noting poor concurrent validity relative to functional measures like the FIM. However it should benoted that only a relatively low correlation with an objectivefunctional measure would be expected, given that the COPMmay not address the same items as the typical functionalmeasure.

Responsiveness (or sensitivity to change) of the COPMwas considered in five studies (Bowie, Shackleton & Zehnal,1999; Carpenter et al., 2001; Chen, Rodger & Polatajko, 2002;Lewis & Jones, 2001; Wressle, Samuelsson & Henriksson,1999). All five reported that the COPM was very responsiveto changes in client outcomes over time and when comparedto other measures such as the Short Form-36, the HealthAssessment Questionnaire and the FIM, demonstratingimprovement in perceived performance and satisfaction.

Finally, one of the most compelling pieces of evidence ofthe psychometric value of the COPM is the fact that it hasbeen used in several studies as the standard against which thevalidity of other disease specific measures of client-centredoccupational performance have been compared. For exam-ple, the COPM has been used to validate the following measures: Unified Parkinson’s Disease Rating Scale andParkinson’s Disease Questionnaire (Gaudet, 2002),Functional Evaluation in a Wheelchair (FEW)(Mills et al.,2002), Dutch Arthritis Impact Measurement Scales 2 (D-AIMS2) (van Meeteren et al., 2000) and the Disabilities ofthe arm, shoulder and hand questionnaire, Dutch version(DASH-DLV) (Veehof, Sleegers, van Veldhoven & vanMeeteren , 2002).

Occupational therapy research outcomesThirty-three (33) articles were identified in which the COPMwas used as an outcome measure in studies of occupational

212 OCTOBRE 2004 ■ REVUE CANADIENNE D’ERGOTHÉRAPIE ■ NUMÉRO 4 ■ VOLUME 71 © CAOT PUBLICATIONS ACE at TEXAS SOUTHERN UNIVERSITY on October 27, 2014cjo.sagepub.comDownloaded from


CARSWELL ET AL.

therapy effectiveness:• Sixteen (47%) used quasi-experimental designs, with

pre- and post-intervention measures on conveniencesamples of clients;

• Two were client surveys (Cooper & Stewart, 1997;Crenshaw Gillian, Kidd, Olivo & Schell, 2001);

• Ten were case studies (Davis, Mulcahey, Smith & Betz,1998; Fragala, O’Neil, Russo & Dumas, 2002; Gillot,Holder-Walls, Kurtz & Varley, 2003;Hannah &Hudak, 2001; Landa-Gonzalez, 2001; Martini &Polatajko, 1998; Reid, 2002; Reid, Rigby & Ryan, 1999;Stevens, Redfearn & Tse, 2003; Tam, Reid, Naumann& O'Keefe, 2002);


TABLE 2Psychometric properties of the COPM.

Study Population Findings

RELIABILITYSewell & Singh (2001) N=15 COPD COPM is a reproducible measure.Cup et al. (2003) N=26 post-stroke Test-retest reliability is moderate for item pool & strong for performance & satisfaction.Pan et al. (2003) N=141 Taiwanese, Test-retest reliability is strong (r=0.842).

mental health disabilityVALIDITYChan & Lee (1997) Orthopaedic & COPM is successful in measuring occupational performance (vs components).

post-stroke COPM does not measure the same aspects as the Klein-Bell - ADL or the FIM.Law, Darrah et al. (1998) N=12 children, COPM scores demonstrate significant clinical and statistical improvement

cerebral palsy during 3 mths of therapy. Comparison of the COPM with measures of gross & fine motor function & disability demonstrate construct validity.

Boyer et al. (2000) N=29 schizophrenia Perceived occupational performance is only a small part of subjective QOL. Theassociation is positive.

McColl et al. (2000) N=61 disabled, Supports the use of the COPM in terms of criterion and construct validity.community dwelling Survey results indicate client satisfaction with the interview process. Supports

the utility of the COPM as a research instrument.Simmons et al. (2000) N=31 sub-acute Predictive scores based on FIM are less accurate in predicting outcome than

nursing facility COPM/FIM scores. COPM enhances the accuracy of the outcome prediction.Improves therapist understanding of clients goals and enhances predictive outcome accuracy.

Van Meeterem et al. (2000) N=57 haemophilia COPM is the standard against which a new measure is validated. It is broaderwith the inclusion of work, self-care & leisure.

Carpenter et al. (2001) N=87 pain clinic Statistically significant associations between COPM & the Beck Anxiety Inventory, Oswestry Disability Scale & Pain Visual Analog Scale. Allows insightinto important targeted problems. Enhances the therapeutic relationship,which the other measures did not.

Lewis & Jones (2001) N=15 residential, COPM is sensitive to change & is an appropriate outcome measure for all 3multidisciplinary, groups of clients. Valid measure of client–perceived performance compared torehabilitation program satisfaction & physical health on the SF-36.

Ripat et al. (2001) N=13 rheumatoid HAQ & COPM do not measure the same attributes but when matched, the arthritis association is statistically significant. Face validity of COPM is superior to HAQ.

Veehof et al. (2002) Upper limb disabilities Concurrent validity (Kappa = 0.79, p<0.001) compares COPM outcomes with the DASH-DLV.

Cup et al. (2003) N=26 post-stroke Discriminate validity confirmed, many unique problems can be evaluated.

RESPONSIVENESSBowie et al. (1999) N=8 interdisciplinary COPM is a very responsive outcome measure compared to the FIM & measures

out-patient program different attributes.Wressle et al. (1999) N=27 occupational Therapists report the COPM enables them to demonstrate meaningful change

therapists in clients & facilitate team planning.Carpenter et al. (2001) N=87 pain clinic Mean score changes on performance & satisfaction were statistically significant

& clinically meaningful.Lewis & Jones (2001) N=15 residential, COPM is more sensitive to change than measures of general health (Short Form

multidisciplinary, 36 & HAQ) & had the lowest coefficient of variation.rehabilitation program

Chen et al. (2002) N=12 neuro Both mean change scores on performance & satisfaction are clinically & statisti-rehabilitation program cally significant on the COPM & the Reintegration to Normal Living Index.

Note: COPD = Chronic Obstructive Lung Disease; DASH-DLV = Disabilities of arm, shoulder and hand; FIM = Functional Independence Measure;HAQ = Health Assessment Questionnaire; OT=Occupational Therapy; QOL= Quality of Life



CARSWELL ET AL.

• Six were randomized controlled trials (Boyd et al.,2003; Gilbertson & Langhorne, 2000; Law et al, 1997;Miller, Polatajko, Missiuna, Mandich & Macnab,2001; Richardson, Law, Wishart & Guyatt, 2000;Vanleit & Crowe 2003).

Client populations on which the studies were undertakenincluded children with disabilities, adults with chronic obstruc-tive pulmonary disease, neurological disabilities, fibromylagia,traumatic brain injuries, older adults with stroke, and hip frac-tures, and community clients with mental health difficulties.


TABLE 3COPM as an outcome measure in occupational therapy.

Study Purpose Findings

Ward et al. (1996) To determine OT outcomes COPM issues had changed 6 mths post-discharge home. Initial rat-for clients with a hip fracture ings did not change but were no longer important to client. Results at 6-mths post-discharge. demonstrate need to follow older clients discharged home.

Cooper & Stewart To determine the effects of Trends in improving COPM performance & satisfaction scores indi-(1997) a home transfer pole on the cate that a transfer pole increases the perception of safety. No

ability of well-elderly residents changes in other measures.to transfer safely.

Law et al. (1997) To evaluate the combined effect COPM shows no differences between 2 therapies. All children have of intensive NDT & casting some gains. COPM goals accentuate treatment importance to par-compared to traditional OT. ents regardless of the type of intervention.

Davis et al. (1998) To determine the efficacy of FES FES increases functional independence as measured by the COPM &on young children’s hand function. ADL tests.

Law, Darrah et al. To describe a pilot evaluation of a COPM demonstrates clinical & statistical improvement permitted (1998) family-centred functional approach parents to identify realistic goals for their children based upon their

to therapy for young children with CP. observations of what their children were attempting to perform.Martini & Polatajko To determine whether verbal self- COPM demonstrates clinical & statistical improvement in perfor-(1998) guidance facilitates behaviour mance & satisfaction. Indicates that verbal self-guidance is an effec-

change in children with DCD. tive approach for enabling children with DCD to overcome their motor challenges.

Bailey et al. (1999) To evaluate a clinical fibromyalgia Results are consistent with RCT findings in literature. Largest gains program (Fibro-Fit). were in the COPM scores; demonstrates that it is important to use a

performance outcome measure.Healy & Rigby (1999) To evaluate The Independence COPM demonstrates clinical & statistical improvement in perfor-

Program (TIP) for teens and mance & satisfaction. Shows that the TIP was beneficial for the 11young adults with disabilities. youth that were involved. COPM permits youth to work on issues

that increase independence.Mason et al. (1999) To determine the effectiveness of Statistically & clinically significant COPM change scores demonstrate

clients with COPD. pulmonary rehabilitation program is effective. COPM is more sensi-tive to change than a measure of ADL.

Reid et al. (1999) To assess whether a rigid anterior pelvic COPM results demonstrate that the pelvic stabilizer improves per-stabilization device for paediatric w/ch ceived performance. COPM helps children focus on success in users leads to improved performance. meaningful activities.

Gilbertson & Langhorne To evaluate a post-discharge OT COPM is more meaningful to clients & sensitive to change over time (2000) outreach service. than a subjective health status & QOL measure. COPM change scores

demonstrate that stroke clients with no communication or cognitiveproblems can benefit from outreach OT.

Richardson et al. To compare traditional OT with a COPM scores demonstrate no support for the use of a simulated (2000) simulated environment (Easy Street) environment (Easy Street). COPM is a responsive measure sensitive

in retraining independent living to observed clinical changes; measures of ADL (SAILS)& health statusskills in older adults. (SF-36) were not sensitive to change over time or intervention.

Stewart & Neyerlin-Beale To establish whether OT enabled child- Significant statistical & clinical improvement on the COPM demon-(2000) ren with disabilities to become more strates that community OT enables children to increase their inde-

independent & reduced the strain of pendence. No change in scores of measures caregiver burden & caring for a child with disabilities. stress demonstrate that the program has little effect on caregivers.

Bickes et al. (2001) To compare 2 treatment methods: COPM results indicate that although overall performance did occupational-based verbal therapy & improve, no significant difference between the verbal group & the occupation-based experiential therapy. experiential group was found.

Bottos et al. (2001) To assess the effect of early provision COPM results demonstrate improvement in children’s mobility & of a powered w/ch in children with independence & indicate that parents acceptance of children’s’tetrapelgia in regard to QOL, indepen- abilities improve.dence and psychological reactions.

Table 3 continued >



CARSWELL ET AL.


Study Purpose Findings

Brown et al. (2001) To evaluate a 12-wk pilot COPM results that although overall performance did improve, it was community living skills group. not clinically or statistically significant.

Cott & Wright To evaluate a program of CE for COPM results did not support CE as means of improving occupa-(2001) adults with a neurological disability. tional performance even though motor function, balance & mobility

did improve.Hannah & Hudak To determine the best splint for COPM performance & satisfaction change scores demonstrate the (2001) improving hand function. most appropriate splint.Hitchon et al. (2001) To determine the effectiveness of COPM change scores demonstrate significant benefit for clients

an arthritis education program. receiving an intensive arthritis educational program.Landa- Gonzalez To report on awareness training & Clinical significant changes in COPM scores demonstrate increased (2001) compensation in individual with TBI. independence. OT focuses on issues of concern to the client &

results in overall improvement in occupational performance.Miller et al. (2001) To pilot procedures that compare COPM demonstrate a significant time effect for performance & satis-

CTA with CO-OP & examine the effect faction & a significant time by treatment interaction. Demonstrates upon motor performance & self- that CO-OP is an effective intervention to improve motor skills in perception of children with DCD. children with DCD.

Perron et al. (2001) To determine the effectiveness of a COPM results indicate a statistically significant increase in perfor-summer camp program on perform- mance & satisfaction; reflects the effectiveness of the summer campance & knowledge among children program.with arthritis.

Chesworth et al. To determine whether the COPM was Significant COPM change scores demonstrated the effectiveness of (2002) appropriate for use with clients with using the COPM as an outcome measure of OT efficacy in clients

a mental health disability. with a mental health disability.Fragala et al. (2002) To document impairment,disability & par- COPM results demonstrate an increase in both the child’s & parent’s

ent satisfaction for children with CP who perception of performance. Supports benefits of Botox injections to receive botulism toxin A(BtA) injections. improve overall performance & parental satisfaction.

Reid (2002) To pilot the effectiveness of a virtual COPM change scores in performance & satisfaction (used as a surro-reality play-based intervention. gate for self-efficacy) demonstrate the viability of virtual reality as an

intervention with children.Tam et al. (2002) To determine the effectiveness of COPM change scores indicate that some children found word pre-

word prediction as a tool to enhance diction to be useful in word copying while others did not.written productivity.

Wressle et al. To determine the impact of the the COPM change scores indicate improvement in occupational perfor-(2002) COPM upon clients’ perception of mance & allows for greater improvement in occupational perfor-

active participation in the rehab- mance for experimental group. Demonstrates the effectiveness of ilitation process. clients participating in determining their OT goals.

Boyd et al. (2003) To determine whether training with or COPM change scores indicate that the experimental (BTX-A) group without intramuscular BTX-A enhances had better functional outcomes than the control group at 3, 6 & 12 function,participation & health-related QOL. mths.

Corr & Wilmer To determine the effectiveness of an COPM change scores were statistically & clinically significant.(2003) individualized work program for Supports the development of an individualized return-to-work

younger adults, post-stroke. program.Petty & Treviranus To demonstrate the effectiveness of COPM change scores were statistically and clinically significant.(2003) the COPM in assessing a Vision Demonstrates the impact of assistive technology irrespective of the

Technology Service. impairment severity & type of assistive device.Vanleit & Crowe To evaluate the impact of an 8-wk COPM change scores were significantly improved for the treatment(2003) psychosocial OT intervention program group over the conventional group. Demonstrates that an opportu-

for mothers who have children with nity to reflect on daily occupations may lead to positive changes in disabilities. the life experiences of mothers of children with disabilities.

Stevens & Tse To determine the outcome of OT Successful OT intervention with the COPM.(2003) intervention for a dual diagnosis client.Gillot et al. (2003) To explore the experiences of 2 post- COPM significant change scores support improved occupational

stoke clients with a CMIT home program. performance as an outcome for CMIT.

Note: ADL = Activities of Daily Living; CE = conductive education; CMIT = Constraint-induced movement therapy; CO-OP = Cognitive Orientation todaily Occupational Performance; CP = Cerebral Palsy; CTA = contemporary OT treatment; DCD = developmental coordination disorder; FES = FunctionalElectrical Stimulation; HAQ = Health Assessment Questionnaire; NDT = neurodevelopmental therapy; OT= occupational therapy; QOL = Quality of Life;TBI = traumatic brain injury; RCT = Randomized Controlled Study.

Table 3 continued



CARSWELL ET AL.

Six of the studies used the COPM to examine the out-comes of conventional occupational therapy intervention(Brown, Shiels & Hall, 2001; Chen et al., 2002; Gilbertson etal., 2000; Stewart & Neyerlin-Beale, 2000; Ward, Jagger &Harper, 1996; Wressle, Eeg-Olofsson, Marcusson &Henriksson, 2002). The authors of these six studies com-mented that in addition to demonstrating the effectiveness ofoccupational therapy interventions through clinical and sta-tistical significance of change scores in both performance andsatisfaction, the COPM enhanced client-centred practice,provided a foundation for goal selection, and allowed forindividualized occupational therapy programs and meaning-ful occupational therapy interventions.

Many of the studies in which the COPM was used as anoutcome measure were aimed at evaluating the effectivenessof specific devices or innovative therapeutic approaches.These include the following interventions:

• Home transfer pole for older adults (Cooper &Stewart, 1997).

• Functional electrical stimulation on hand function ina child with tetraplegia (Davis et al., 1998).

• Rigid anterior pelvic device for children with cerebralpalsy (Reid et al., 1999).

• Early use of a powered electric wheelchair in childrenwith tetraplegia (Bottos, Bolcati, Sciuto, Ruggeri &Feliciangeli, 2001).

• Vision technology service (Petty & Treviranus, 2003).

• Hand splints in an older adult (Hannah & Hudak,2001).

Therapeutic approaches that were evaluated positivelyincluded:

• Botox injections to improve children’s physical performance (Boyd et al., 2003; Fragala et al., 2002).

• Independence program for adolescents with disabili-ties (Healy & Rigby 1999).

• Virtual reality play for children (Reid, 2002).

• Community or out-patient occupational therapy(Brown, Shiels & Hall, 2003; Gilbertson et al., 2000;Mason, Singh & Morgan, 1999; Stewart & Neyerlin-Beale, 2000).

• Education programs for clients ( Bailey, Starr,Alderson & Moreland, 1999; Cott & Wright, 2001;Hitchon, Chan, Strock & Canvin, 2001).

A number of studies compared the outcomes of conven-tional occupational therapy with innovative occupationaltherapy interventions (Bickes, DeLoache, Dicer & Miller,2001; Law et al., 1997; Miller et al., 2001; Richardson et al.,2000; Vanleit & Crowe, 2003). In all of these instances, theCOPM demonstrated that clients’ perceptions of their perceived change in both occupational performance and satisfaction with that performance were significantly greaterfor the innovative therapy over conventional therapy.

Occupational therapy practiceFinally, thirty-three (33) studies were identified thatdescribed the role of the COPM in supporting the practice ofevidence-based, client-centred occupational therapy. Thereare opposing views as to the clinical usefulness of the COPM.Occupational therapists generally reported that the COPMwas effective in engaging clients in the therapeutic process, insetting appropriate therapeutic goals, in providing effectivefeedback to team members and clients, and in assessing awide range of client problems (Chesworth, Duffy, Hodnett &Knight, 2002; Gaudet, 2002; McGavin, 1998; Mew & Fossey,1996; Mills et al., 2002; Norris, 1999; Pollock & Stewart, 1998;Trombly, Radomski, Trexel & Burnet-Smith, 2002:Tryssenaar, Jones & Lee, 1999; Waters, 1995; Warren, 2002).However, some studies also indicated that the COPM waslimited to specific clients and/ or therapists.

On the negative side, a few papers reported limitations ofthe COPM as stated by some occupational therapists:

• The COPM was not appropriate for their clientsbecause of the practice setting (Toomey et al., 1995;Wressle et al., 2002).

• Their clients lacked sufficient insight to use theCOPM (Tryssenaar et al., 1999; Waters, 1995).

• Therapists found that their clients had difficultyunderstanding the rating scales for performance andsatisfaction (Bodiam, 1999; Norris, 1999; Petty &Treviranus, 2003).

• The COPM was not sufficiently performance-based(regarding affective, physical, and cognitive compo-nents) to provide the information they needed(Gaudet, 2002).

Despite these reservations, the literature shows that theCOPM has been successfully used with a wide variety ofclients, including:

• Homeless people (Tryssenaar et al. 1999)

• Outpatients (Bowie et al., 1999)

• Palliative care clients (Norris, 1999),

• Clients with mental health needs (Chesworth et al.,2002)

• Clients in a neuro rehabilitation unit (Bodiam, 1999;Trombly et al., 2002)

• Long-term stroke survivors (Reid, Hebert & Rudman,2001)

• Children with a disability and their family members(Lyons & Raghavendra, 2003)

• Older adults living in a care facility (Atwal, Owen &Davies, 2003)

In addition, a number of studies showed how the COPMcould be used to gather information from proxy respondentson behalf of clients who cannot report reliably on their ownoccupational performance. For example, the COPM has beenused with family caregivers of persons with Alzheimer



CARSWELL ET AL.


TABLE 4Clinical utility of the COPM.

Author/Date Purpose Findings

Waters (1995) To document a client’s use of the COPM ensures that therapy was directed by client in partnership withCOPM. therapist. Best used with clients who have insight into their needs.

Mew & Fossey To describe clinical reasoning COPM helps to highlight what client-centred practice means to the(1996) through the use of the COPM. practice of OT.Ward et al. (1996) To compare clients’ occupational COPM facilitates client-based therapy & provides therapists with the

performance problems with those opportunity to assess a range of client therapeutic problems.identified by therapists.

Packer & Xiaoping To determine the most frequently Independence in self-care activities is held as a priority for both men (1997) self-identified functional problems and women in-patients in China and should inform programs for edu-

(self-care, productivity & leisure) in cating occupational therapists in China.order to design education programs to be responsive to client needs.

Creswell (1998) To determine whether the COPM is COPM is an effective & clinically useful tool for community mental useful in community mental health. health as an outcome measure.

McGavin (1998) To determine how rehabilitation goals COPM provides a basis for facilitating independence in adolescents differ between parents & adolescents. with disabilities & meeting the concerns of their parents.

Pollock & Stewart To increase understanding of COPM is child focused while an interview tends to reflect issues impor-(1998) occupational performance needs of tant to the interviewee & may miss addressing issues important to the

young school-aged children with child. COPM permits consideration of the child in every interaction & physical disabilities in the school permits individualized, flexible services. COPM allows collaboration.system & to identify how therapists can help meet the needs.

Trombly et al. To determine whether persons with Subjects & significant others were aware of progress. Clients with a (1998) TBI who received goal-specific OT goal-specific program of OT improved. COPM is a strong measure for

achieved self-identified goals related to determining client chosen goals.their tasks of daily life.

Bodiam (1999) To evaluate whether the COPM could be used COPM is a useful outcome measure for a neuro rehabilitation unit.in patients with neurological impairments.

Bowie et al. To compare the COPM with the FIM. COPM is a useful outcome measure for clients in an outpatient rehabili-(1999) tation program.Fedden et al. To describe how the COPM was used COPM was a successful outcome measure that defines the uniqueness (1999) in a community environment. of the profession.Norris (1999) To assess the effectiveness of the COPM addressed individual, subjective goals upon which OT interven-

COPM as an outcome measure of OT tion was based. Psychological element is missing and thus the COPM is intervention in a palliative care day unit. of limited value in palliative care.

Tryssenaar et al. To examine the occupational COPM useful for assessing occupational performance needs of those (1999) performance needs of homeless who are homeless. Augment COPM with questions related to environ-

individuals. ment, relationships, housing and spirituality. The homeless have occu-pation performance needs.

McGrath et al. To explore the impact of caring for a COPM is useful in helping caregivers to identify occupational perfor-(2000) family member with AD & discover the mance issues for themselves & the person for whom they were caring.

perceived influence of respite on occupational performance.

Packer et al. To determine whether clinical fieldwork COPM pre- and post- module change scores were clinically significant (2000) where there were no established and showed that innovative approaches of self-directed learning mod-

occupational therapists could enable ules, learning contracts and unique supervision related to OT fieldworkstudents to help clients improve in Russia was successful.occupational performance.

Veneri (2000) To examine the relationship of child- COPM is easily used by grade school children. Adults were less positive ren’s occupational performance percep- about children’s problems than the children.tions with those of teachers & parents.

Crenshaw et al. To describe assisted living residents’ COPM can be used to determine meaningful occupation by allowing(2001) perceptions of occupational the residents to identify their own needs & thus have a sense of control

performance issues. over their environment.Drew & Rugg To determine the range & frequency of Survey of 54 students using the COPM to classify client-centred activi-(2001) client-based therapeutic activities seen ties experienced by the students helped to inform educational curric-

by OT students in different practice settings. ula. Reduces the potential gap between education & practice.Dreyer et al. (2001) To determine the clinical utility of the COPM is ideal for assessment via telemedicine because it requires

COPM in telemedicine. verbal responses.Table 4 continued >



CARSWELL ET AL.

Disease (McGrath , Meuller, Brown, Teitelman & Watts, 2000),and caregivers with minor children (Lyons & Raghavendra,2003; McGavin, 1998; Pollock & Stewart, 1998; Veneri, 2000).

A number of articles also exist that demonstrate the use-fulness of the COPM in a variety of different countries andsettings (Chen et al., 2002; Packer & Xiaoping, 1997; Packeret al., 2000; Veehof et al., 2002; Wressle al., 1999). These attestto the international versatility and cultural applicability ofthe COPM, even despite the fact that it was developed withina Canada cultural context and contains the word Canadian inthe title.

DiscussionThe objective of this review was to assemble research infor-mation on the published literature pertaining to the COPM,and to examine its impact on occupational therapy. In particular, this review has considered the COPM from theperspective of its measurement properties, its utility as anoutcome measure and its practical usefulness in therapy.

The review suggests that the measurement properties(reliability, validity, responsiveness) of the COPM repeatedlyhave been shown to be satisfactory to excellent, including theSwedish and Dutch translations. It has been suggested that


Author/Date Purpose Findings

Reid et al. (2001) To compare problems in occupational COPM indicated that 3-5 years post-stroke, survivors & caregivers performance as identified by clients identified similar problems (57% self-care, 11% productivity and 32% & by their caregivers. leisure) that could benefit from OT intervention.

Southon (2001) To discover whether occupational COPM indicates that goals change with location (hospital = self-care performance goals for the older adult and domestic goals, home = household management and leisure differed according to living environment. goals). Goals increase in importance at home.

Chen et al. (2002) To determine the clinical utility of Using the COPM gave therapists insights into their client’s needs.the COPM. Enables more goal-directed interventions, enhances the therapeutic

relationship, & enables a partnership between the therapists & clients early in therapy.

Chesworth et al. To determine whether the COPM was Using the COPM clients were able to clearly identify goals (15% (2002) appropriate for use for clients with a self-care, 23% productivity & 62% leisure). Significant COPM change

mental health disability. scores demonstrate the effectiveness of using the COPM as an out-come measure for clients with a mental health disability.

Gaudet (2002) To examine & recommend measures Including the COPM with a battery of other tests improves the effec-to meet the needs of clients with PD tiveness of an assessment for clients with PD.& the occupational therapist.

Mills et al. (2002) To develop an outcome measure to COPM provided consumer input related to occupational performance,determine functional performance of which provides the basis for a client-centred outcome measure for consumers using seating & w/ch systems. w/ch users.

Reinhartz (2002) To provide data that supports a referral COPM was used to generate themes that became the basis for referral system containing occupation-based to OT. Therapists & clients were pleased with the new referral system, as therapy goals. it appears to be more meaningful.

Trombly et al. To compare the outcomes of goal- Using the COPM to enable clients to participate in goals setting & (2002) specific OT. developing goal-specific OT significantly improves OT outcomes.Wressle et al. To determine the impact of the COPM COPM engages clients in the therapeutic process from the beginning & (2002) on clients’ perception of active becomes an active participant in the rehabilitation process.

participation in the rehabilitation process.Warren (2002) To formulate an OT assessment form based A combination of the COPM with assessment of CMOP components

upon the Canadian Model of Occupational produces an assessment form that can be used in mental health practice.Performance & incorporating the COPM.

Wressle et al. (2002) To determine the clinical usefulness of The COPM is useful in setting goals and planning interventions, facili-the COPM. tates feedback & communication in teams & provides therapists with a

client-centred perspective. Limited use for clients with no insight.Therapists need to understand underlying theory.

Atwal et al. (2003) To determine the types of occupations Using the COPM to define occupation for older adults demonstratesreported by older adults living in care that continued active engagement in occupation is important for older homes. adults living in care homes.

Landi et al. (2003) To determine the best measure of COPM is an outcome measure capable of crossing cultural boundaries cultural, social & personal dimensions & allowing for the comparison of interventions.of disability.

Lyons & To determine whether the COPM can be COPM is an effective outcome measure in an early Raghavendra (2003) used in a multidisciplinary team. intervention, multidisciplinary team.

Note : AD = Alzheimer’s Disease ; FIM = Functional Independence Measure ; PD = Parkinsons disease ; RCT = Randomized Control Study; TBI = TraumaticBrain Injury

Table 4 continued



CARSWELL ET AL.

further research is required to examine the inter-rater relia-bility of the COPM. However because COPM occupationalperformance problems and scores are client driven (the clientis the rater) inter-rater reliability is not testable as each clientwill determine problems and scores particular to his/her ownsituation. Thus the consistency of responses can only be mea-sured as test-retest reliability.

The COPM is not for all clients or all occupational therapists. Some articles noted that the COPM was notappropriate for clients who lacked insight (Boyer et al., 2000;Crenshaw et al., 2001; Robertson, 2002; Warren, 2002), thosewho had dementia (Toomey et al., 1995) or those who reliedon health care professionals to make decisions for them(Bodiam, 1999; Donnelly & Carswell, 2002). From the outsetthis issue has been a source of tension regarding the COPM.The COPM captures the client’s perspective about his or heroccupational performance problems and the things he or shewishes to work on in occupational therapy. Without somemeasure of the client’s perspective, it is difficult to imaginehow one might engage in client-centred therapy. Further-more we suggest that even the client with very little insighthas a perspective on what he or she thinks is wrong and whatneeds to happen to remedy the problem. In the absence ofthis perspective, a therapist is forced either to take a profes-sionally dominated approach, or to accept the proxyresponses of an informant on behalf of the client. Admittedly,among clients who are non-communicative or whose cogni-tion is impaired, there are additional challenges to using theCOPM. However, for the therapist who is committed toworking from a client-centred approach, the client’s perspec-tive is essential and the COPM is one of a relatively short listof assessments which helps to elicit this.

It is also clear that the COPM is neither an objectivemeasure of functional independence, nor is it a measure ofperformance components, such as physical or psychologicalfunctioning. It does not address a pre-determined list offunctions, such as bathing, dressing and meal preparation,for example. Instead, it evaluates occupation in its entirety(productivity, self-care and leisure), focussing on the occupa-tional performance problems that are most salient to theindividual at the time of assessment (Carswell, 1995;Donnelly & Carswell, 2002: Law et al., 1991). It is ideallysuited to what could be what Trombly (1995) called the top-down approach to assessment, where occupational performance problems are identified first, and then theunderlying causes are further assessed using measures ofperformance components (Backman & Medcalf, 2000).

Nevertheless, the studies reviewed in this paper defendthe effectiveness and usefulness of the COPM as an occupa-tional performance evaluation for clients with a wide spec-trum of impairments and conditions, using qualitative andquantitative research paradigms and in a variety of practicecontexts. This review clearly shows that the COPM is useful,

allows clients to identify their occupational needs, is effectivein quantifying change in occupational performance related tooccupational therapy interventions, facilitates discussion andnegotiation between clients and family caregivers and givesthe therapist a strong base upon which to develop meaning-ful and effective occupational therapy strategies.

With the increasing accountability regarding the spiral-ling costs of health care, and downsizing of occupationaltherapy programs, the profession needs to embrace outcomesresearch that will demonstrate the clinical and cost effective-ness of occupational therapy interventions (Bowman &Llewellyn, 2002) and facilitate clinicians’ ability to engage inevidence-based practice (CORE, 2003). The findings indicatethat the COPM, based upon the Canadian Model ofOccupational Performance, allows occupational therapists tomonitor the impact and the cost of their interventions, todetermine which therapeutic approach is most effective forspecific clients and for the cost of the intervention, and todevelop individualized intervention programs to meet thespecific therapeutic needs to their clients.

The impact of the COPM on occupational therapy out-come research is considerable and it is expected that theCOPM will be used for further research in relation to occupa-tional therapy outcomes. The evidence for occupationaltheapy effectiveness is essential if the profession is to continueto develop and meet the therapeutic needs of clients. Thisreview is an authentication of a growing body of comparable,empirical outcome evidence demonstrating the effectivenessand efficacy of occupational therapy interventions available tothe profession, and to therapists and their clients.

SummaryThe articles in this review that addressed occupational therapypractice demonstrate that the COPM facilitates therapists tofocus on client needs, to develop meaningful interventionstrategies and to demonstrate concrete and significant changescores attributable to occupational therapy practice.

This review demonstrates that since its development andpublication, the COPM has become an accepted outcome measure for occupational therapists. It is the subject of bothempirical and descriptive papers, which espouse the COPM asa reliable, valid, clinically useful, and responsive outcome mea-sure that can be used to provide empirical evidence of the effec-tiveness of client-centred occupational therapy intervention aswell as a basis for occupational therapy outcomes research.

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CARSWELL ET AL.

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AuthorsAnne Carswell, PhD, FCAOT, OT Reg. (Ont.) is an Associate

Professor, Department of Occupational Therapy University ofToronto, Department of Occupational Therapy, Suite 160, 500University Ave. Toronto, ON. M5G 1V7.E-mail: Anne. [email protected]

Mary Ann McColl, PhD, FCAOT, OT Reg. (Ont.) is a Professor,Community Health and Epidemiology, Occupational Therapy,Queens University, Kingston, ON.

Sue Baptiste, MHSc, FCAOT, OT Reg. (Ont.) is an AssociateProfessor and Assistant Dean (OT), School of RehabilitationScienceMcMaster University, Hamilton, ON.

Mary Law, PhD, FCAOT, OT Reg. (Ont.) is a Professor andAssociate Dean, School of Rehabilitation Science,McMaster University, Hamilton, ON.

Helene Polatajko, PhD, FCAOT, OT Reg. (Ont.) is a Professor andChair, Department of Occupational Therapy, University ofToronto, Toronto, ON.

Nancy Pollock, MSc, OT Reg. (Ont.) is an Associate ClinicalProfessor, Occupational Therapy, School of Rehabili-tationScience, McMaster University, Hamilton, ON.

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the canadian occupational performance measure: a research and clinical literature review

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