cardiac diseases are as the leading cause of death in the modern world and they can result 
 in early death , morbidity and disability of the population making them a serious public 
 health problem in the world1 .
cardiac 
 diseases are systemic and progressive diseases , and they are characterized by functional 
 limitations in daily activities that are caused by clinical symptoms , shortness of breath or 
 fatigability .
patients with cardiac diseases report difficulties in a variety of 
 activities2 . in most elderly people who suffer from cardiac diseases ,
show a gradual loss of ability to 
 perform physical activities resulting in loss of independence in performing daily 
 activities3,4,5 .
functional limitations 
 manifest as difficulty in performing daily activities6 . these restrictions of cardiac diseases mostly arise from a 
 combination of physical limitations , symptoms and numerous hospitalizations6 , 7 . 

furthermore , disabilities or activity limitations are important determinants of quality of 
 life8 . according to the international 
 classification of functioning , disability and health9 , ( icf , formerly icidh-2 http://www.who.int/classification/icf ) , 

activity limitations are the difficulties that an individual may have in executing a task or 
 an action , while participation restrictions are the problems an individual may experience in 
 involvement in life situations .
icf belongs to the family of international classifications 
 developed by the world health organization ( who ) for application to various aspects of 
 health9,10,11,12 .
despite the fact that the functional decline in cardiac disease patients reflects disease 
 progression , evidence for functional limitations has not been sufficiently demonstrated . 

cieza et al.13 , represented icf core sets 
 for chronic ischemic heart diseases and linked specific conditions or diseases to salient 
 icf categories of functioning .
several questionnaires have been reported to measure the 
 functional limitations of patients with cardiac diseases14,15,16,17 .
however , these 
 questionnaires were originally developed to measure health - related quality of life ( hrqol ) 
 or health status .
the factors of functional limitation that are contained in these 
 questionnaires have not been studied independently from the viewpoint of cardiac disease 
 status7 .
furthermore , cardiac diseases 
 have not been adequately examined with an objective , condition specific , health status 
 measurement tool . the canadian occupational performance measure ( copm)18,19,20 is a client - centred , patient reported outcome measure with which 
 clients evaluate their occupational performance and satisfaction with performance in areas 
 of self - care , productivity and leisure .
occupational therapy has newly developed assessing 
 the occupational performance measurements for patients with cardiac diseases , and it is an 
 important concept to increase the awareness of necessity of occupational therapy for this 
 group of patients .
also we recognized that there is surprisingly little research has 
 identified the activity performance problems and participation restriction of patients with 
 cardiac diseases in the literature1 , 7 , 8 , 13 .
the aim of this study was to determine 
 the client - centred activity performance problems of patients with cardiac diseases .
a second 
 objective of the study was to analyze associations between activity performance and 
 satisfaction with quality of life .
consecutive stable subjects ( n : 82 ) , who were diagnosed as having cardiac diseases were 
 recruited and at consulted to the physical therapy department , between the dates march 2013 
 to march 2014 . twelve subjects were excluded from our study because they had other diseases 
 could have affected our results such as cancer or orthopedically problems , so the interviews 
 conducted with 70 cardiac diseases patients ( mean age : 60.112.0  years , bmi : 
 26.04.0  kg / m ) .
the following cardiac conditions were included in the study : coronary artery diseases 
 ( angina pectoris , myocardial infarction ) , heart failure , and subjects who had been diagnosed 
 as having coronary artery disease after an angiography procedure .
clinical cardiac disease 
 diagnoses were made by a cardiologist and then subjects were referred to the physical 
 medicine and rehabilitation department for the interviews .
the definition of angina pectoris 
 was characterized as a chest pain occurring due to exertion which was alleviated by 
 nitro - glycerine or by rest .
myocardial infarction was defined as previous history or a 
 previous occurrence of it detected by electrocardiography or newly diagnosed myocardial 
 infarction by blood enzyme levels .
the inclusion criteria were the patients who were over 
 18  years of age , whose native language was turkish , and who had perceived limitations in 
 more than one activity of daily life .
the exclusion criteria of the present study were 
 cognitive deficits affecting the assessments , and functional problems not related to the 
 cardiac diseases , or the patients who were at the beginning or the end stages of the heart 
 failure .
all of the subjects were receiving their optimal pharmacological therapy and all of 
 them were clinically stable .
the interviews were carried out before the participants were 
 discharged from hospital and were performed at the physical medicine and rehabilitation 
 department .
this study was approved by the university institutional review board and ethics 
 committee ( project no : ka14/12 ) .
the 
 participants completed an interview with an occupational therapist , which addressed activity 
 limitations and participation restrictions .
copm is now a widely used and accepted 
 outcome measure for clients with chronic conditions18 , 21,22,23 and has been validated 
 for the turkish population24 .
the copm 
 permits the identification and measurement of problems of particular concern to the patient . 

it is an individual and a client - centered outcome measure designed according to this 
 perspective to help detect gradual changes in client self - perception of occupational 
 performance and satisfaction in the areas of self care , productivity and leisure times .
it 
 is a semi - structured interview , in which a therapist helps the client to identify his or her 
 problems performing daily activities .
this outcome measurement is used for various diagnoses 
 and in all developmental stages18 , 21 , 25 .
all of the copm interviews in this study took place in the hospital 
 and were conducted by the same trained therapist . during the interviews ,
the patients were 
 encouraged to identify any daily activity that they would like or need to do but found 
 difficult to complete because of their cardiac diseases .
patients then identified the five 
 most important daily activities and rated , first , their current level of performance , and 
 then , how satisfied they were with this current level of performance .
these performance and 
 satisfaction scores were rated by on a 10-point scale , with higher scores indicating better 
 performance and satisfaction18 , 20 .
the nottingham extended activities of daily living ( neadl ) scale is another scale that is 
 used for assessing activity limitation in patients with cardiac diseases .
the neadl is 
 frequently used in clinical practice and research in rehabilitation research to assess 
 patients independence in activities of daily living and has been validated for the turkish 
 population26 .
twenty - two activities are 
 considered , which fall into 4 subscales : mobility , kitchen , domestic , and leisure 
 activities .
responses are recorded using 1 of 4 options ( not at all=0 , with help=1 , on my 
 own with difficultly=2 , on my own=3)26 , 27 . during the interviews to detect the 
 impact of activity limitations on quality of life ,
the nhp is designed to be a standardized and simple measure of subjective health 
 status in the physical , social and emotional domains .
the nhp is a questionnaire designed to 
 measure the social and personal effects of illness .
it is used as a measure of need of 
 health care and as an outcome measure in evaluation . among groups of subjects ,
it correlates 
 well with objective measures of health status and it is sensitive to change with disease 
 severity .
it has 38 questions ( requiring a yes / no response ) on energy , pain , emotion , sleep , 
 social isolation , and physical abilities and the scores of each component are weighted to 
 give a score from 0 to 10028 .
the nhp has 
 been proved to be valid and reliable for several groups of patients29 , 30 and a turkish 
 validation has been carried out31 .
the statistical software spss 20 ( ibm corp . released 2011 ibm spss statistics for windows , 
 version 20.0 armonk , ny : ibm corp . )
the data are presented as the 
 mean and standard deviation for the continuous variables and percentages for the categorical 
 data .
the number of patients identifying each activity as one of their major problems was 
 determined .
ratings of performance and satisfaction were calculated for each patient as the 
 mean of the scores of the main problem activities of that patient .
the sample size was determined 
 based on statistical power analysis procedures using pass 2005 software ( ncss , kaysville , 
 ut , usa ) .
the power analysis indicated that 66 participants were needed for 80% power and a 
 5% type 1 error .
the power analysis of our study showed a power of 80% with activity 
 performance measurement as the primary outcome . in case of dropouts estimated subject s 
 number at least 20% increased .
the socio - demographic and clinical characteristics of patients are presented in table 1table 1.sociodemographic and clinical characteristics of the participantsvariablesmeansdage ( years)60.212.0bmi26.14.1frequency%gendermale4665.7female2434.3level of educationno education11.4primary school2028.6secondary school1115.7high school1521.4bachelor2130master degree11.4doctoral degree11.4occupationemployee1318.6unemployed710retired4564.3unemployed because of the disease57.1marriage status single22.9married6288.6divorced11.4widow57.1smoking habitsmoker1217.1non - smoker1622.9ex - smoker4260exercise habityes912.9diagnosis myocardial infarction2028.6coronary angiography ( cad ) 2231.4angina pectoris ( cad)1420heart failure1420sd : standard deviation , bmi : body mass index , cad : coronary artery disease ( p>0.05 ) .
the most commonly described problems were walking ( 45.7% ) , climbing up the 
 stairs ( 41.4% ) , bathing ( 30% ) , dressing ( 28.6% ) and outings ( 27.1% ) .
table 2table 2.frequencies of activity performance problems of patients with cardiac 
 diseasesactivities%activities%walking45.7playing tennis5.7climbing stairs41.4playing volleyball5.7bathing30washing hand and face5.7dressing28.6putting on shoes5.7outings27.1nature walking5.7putting on socks24.3cleaning windows5.7speaking22.9working4.3driving17.1breathing4.3playing sports18.6feeding farm - animals4.3shopping at the bazaar17.1going to the restroom4.3cooking 15.7painting walls2.9shopping14.3riding a bicycle2.9cleaning14.3meeting with friends or relatives1.4gardening12.9staying in a closed area1.4lifting weights12.9combing hair1.4running12.9peeling eggs1.4reading a newspaper11.4cutting firewood1.4taking pills8.6playing the baglama1.4swimming8.6going to the cinema1.4shaving8.6eating1.4washing dishes7.1reading book1.4washing clothes7.1going to hunting1.4knitting7.1going on holiday1.4 shows all of the patients occupational performance problems .
sd : standard deviation , bmi : body mass index , cad : coronary artery disease patients performance limitations were scored on the copm .
the correlation coefficients of 
 the copm performance score and all the subgroups scores of neadl and nhp ( total , energy , and 
 physical ability ) subgroup scores were statistically significant ( p<0.05 ) .
there were 
 significant relations between all subgroups of neadl and nhp : total , energy , and physical 
 ability subgroup scores ( p<0.05 ) .
there was no relationship between copm satisfaction 
 scores and the other outcome measurements ( p>0.05 ) .
the significant correlations are 
 shown in table 3table 3.significant correlations between activities of daily living and quality of life 
 measurementsmeasurementscopmperformancescoreneadltotal scoremobilitykitchendomesticleisure activitiesrrrrrrnhptotal score -0.464 * -0.485 * -0.471 * -0.356 * -0.376 * -0.366*energy-0.317 * -0.395 * -0.394 * -0.453 * -0.592 * -0.438*physical abilities-0.406 * -0.579 * -0.547 * -0.417 * -0.506 * -0.305*neadlmobility0.356*kitchen0.382*domestic0.472*leisure activities0.359*total score0.441**p<0.05 , copm : canadian occupational performance measurement , nhp : nottingham 
 health profile , neadl : nottingham extended activities of daily living .
descriptive analysis results of these outcome measurements are shown in table 4table 4.descriptive results of the outcome measurementsoutcome measurementsmeansdcopm performance score5.501.96copm satisfaction score8.541.54nhpenergy36.5933.39pain18.0517.41emotion24.3621.08sleep27.5826.74social isolation12.3719.28physical abilities 30.9226.46total score149.5478.0neadlmobility4.921.83kitchen4.041.80domestic3.121.40leisure activities4.821.68total score16.945.82sd : standard deviation , copm : canadian occupational performance measurement , nhp : 
 nottingham health profile , neadl : nottingham extended activities of daily living .
* p<0.05 , copm : canadian occupational performance measurement , nhp : nottingham 
 health profile , neadl : nottingham extended activities of daily living sd : standard deviation , copm : canadian occupational performance measurement , nhp : 
 nottingham health profile , neadl : nottingham extended activities of daily living
recent suggestions for the treatment of the heart diseases focus on increasing the quantity 
 of life ( preventing disease and death ) and improving the quality of life by reducing the 
 symptoms .
the recognition of the importance of systematically examining symptoms and 
 functional restrictions to tailor the management of cardiac diseases has led to the use of a 
 number of condition specific , health status measures13 , 16 , 17 , 32 , 33 .
patient - reported outcomes are any report of the status of a 
 patient s health condition that comes directly from the patient , without interpretation of 
 the patient s response by a clinician or anyone else . the outcome can be measured in 
 absolute terms ( e.g. , severity of a symptom , or impact of a symptom ) , or as a change over 
 time .
there is a growing recognition of the 
 importance of a patient perspective on health after medical treatment of cardiovascular 
 disease .
patient - reported outcomes can provide an additional measure complementary to 
 objective biomedical measures35 . despite 
 the continued rise in reporting of patient - reported outcomes in cardiovascular trials , such 
 outcomes were still underused in many trials , even after taking account of their relevance 
 to individual trials36 .
patient specific measures such as the copm can act as a tool to encourage patients and 
 professionals to jointly participate in goal - setting in a client centred perspective37 .
there is no study that has used the copm 
 as an assessment tool for in clients with cardiac diseases .
it is mentioned in a review that 
 copm , which is an open - ended goal - setting tool , may , if administered carefully , provide an 
 opportunity for the patients with cardiac disease to express their desires , both in the 
 present and the future38 .
the results of this present study confirm that patients with cardiac diseases have 
 considerable functional limitations .
the results of this study also suggests that the copm may be a 
 useful patient - reported assessment tool for measuring activity limitation and participation 
 in cardiac diseases , and permits the determination of the aspects of performance that are of 
 greatest relevant to the cardiac patients .
the most commonly reported occupational problems 
 were about self - care and mobility activities .
a previous study has mentioned that functional 
 limitations in cardiac diseases primarily arise from clinical symptoms which are due to not 
 only cardiac dysfunction but also systemic factors , such as skeletal muscle dysfunction4 .
therefore , activity limitations defined by 
 copm describes the disease specific limitations of cardiac diseases .
fihn et al.39 recommended a wide range 
 of tools for monitoring and providing risk stratification of cardiac patients .
clinical 
 markers , such as electrocardiography , echocardiography or exercise testing , tend to be 
 expensive and invasive . however , copm is non - invasive , cost effective and easy to 
 administer .
this patient - reported outcome measurement may have an important role in clinical 
 research and disease management programmes for cardiac diseases . in this study ,
the most commonly described problem was walking tolerance , which was 
 identified as one of the most important problems by 45.7% of patients , and the other 
 commonly described problems were climbing stairs ( 41.4% ) , bathing ( 30% ) , dressing ( 28.6% ) 
 and outings ( 27.1% ) . on the other hand ,
other different activity performance problems 
 identified were like knitting , playing the baglama ( a music instrument ) , going to hunting , 
 or peeling eggs , etc .
clinicians can learn from patients traditional activity performance 
 problems such as walking , or stair climbing , but it is important for patients quality of 
 life to uncover the real problem .
when the clinician or therapist knows all of a patient s 
 activity performance problems they can plan more suitable rehabilitation programs . as it has 
 indicated in this study , copm also describes some cultural differences that could affect the 
 disease progress . in this
study the associations between activity limitation and quality of life were 
 significant , especially the physical ability dimension of the quality of life measurement . 

the results showed that the systemic and central effects of the cardiac diseases may 
 influence the development of the activity limitation and reduce patients quality of life . 
 on the other hand
there was no relationship between patients satisfaction about their 
 activity performance and nhp or neadl .
this situation reflects the fact that patients 
 satisfaction is not exclusively related to performance of daily living activities . 

administering the copm for patients with cardiac diseases is important for evaluating their 
 satisfaction with activity performance .
a second limitation is the cross sectional design of 
 our study , which only enables examination of associations between dimensions of functioning . 

our participants had only coronary artery diseases ( angina pectoris , 
 myocardial infarction ) , heart failure , or were patients who received for angiography . 

therefore , more types of cardiac patients should be included in the future studies or 
 different cardiac conditions should be analyzed . in conclusion , cardiac diseases ,
their assessment and treatment are major challenges for 
 health care providers throughout the world40 . in this study
, it was found that patients with cardiac diseases 
 reported problems with diverse activities .
it has considerable merit as a measure of cardiac 
 patients capacity for engaging in activities which are important to their quality of 
 life .
 [ purpose ] to describe the functional consequences of patients with cardiac diseases and 
 analyze associations between activity limitations and quality of life . 
 [ subjects and 
 methods ] seventy subjects ( mean age : 60.112.0  years ) were being treated by physical 
 medicine and rehabilitation and cardiology departments were included in the study . 
 
 activity limitations and participation restrictions as perceived by the individual were 
 measured by the canadian occupational performance measure ( copm ) . 
 the nottingham extended 
 activities of daily living ( neadl ) scale was used to describe limitations in daily living 
 activities . to detect 
 the impact of activity limitations on quality of life the nottingham 
 health profile ( nhp ) was used . 
 [ results ] the subjects described 46 different types of 
 problematic activities . 
 the five most identified problems were walking ( 45.7% ) , climbing 
 up the stairs ( 41.4% ) , bathing ( 30% ) , dressing ( 28.6% ) and outings ( 27.1% ) . 
 the 
 associations between copm performance score with all subgroups of neadl and nhp ; total , 
 energy , physical abilities subgroups , were statistically significant . 
 [ conclusion ] our 
 results showed that patients with cardiac diseases reported problems with a wide range of 
 activities , and that also quality of life may be affected by activities of daily living . 
 
 copm can be provided as a patient - focused outcome measure , and it may be a useful tool for 
 identifying those problems . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION