Perceptions of goal setting in a neurological rehabilitation unit: a qualitative study of patients, carers and staff

OBJECTIVE: To explore perceptions of goal setting from the perspective of patients, lay carers and rehabilitation staff. DESIGN: Semi-structured interviews analysed independently by 2 researchers using content analysis. SETTING: Neurological rehabilitation inpatient unit for adults. SUBJECTS: Four samples of 10 subjects each, comprising: (i) inpatients, (ii) patients discharged within the last 2 years, (iii) lay carers, (iv) staff. Patients, carers and staff had participated in at least 2 goal setting meetings, patients had any non-progressive neurological condition causing disability and need for inpatient rehabilitation. INTERVENTION: Goal setting meeting. Main outcome measures: Themes identified independently before results triangulated to produce consensus list presented as frequency tables across 4 subject groups. Quotations from narratives used to clarify themes. RESULTS: All 4 groups considered goal setting to be beneficial, increasing motivation and providing reassurance for patients and carers. Carers found goal setting alleviated some anxieties and assisted active problem-solving coping strategies. Staff believed that goal setting made their practice more focused and collaborative because they were working towards stated and shared goals. Specific improvements were suggested regarding education, nature of goals, conduct of meetings and feedback. CONCLUSION: Goal setting appears to provide psychological benefits to patients and carers.     

The effect of botulinum toxin type A treatment of the lower extremity on the level of functional abilities in children with cerebral palsy: evaluation with goal attainment scaling

OBJECTIVE: To measure the effect of botulinum toxin type A (BTX-A) treatment in children with cerebral palsy with regard to individual goals concerning functional abilities, using goal attainment scaling. DESIGN: A single-blind randomized multiple baseline/treatment phase design across subjects. SETTING: The paediatric department of a rehabilitation centre. SUBJECTS: Eleven children with cerebral palsy participated. INTERVENTION: BTX-A treatment of the lower extremity. MAIN MEASURES: A six-point goal attainment scaling of three individual treatment goals at the level of functional abilities. Standardized video-tapes of each goal were recorded weekly for a period of 14 weeks. Rating on the predetermined goal attainment scaling was blinded. RESULTS: Nine of the 11 subjects showed significant improvement in 18 out of 33 goals. Seven subjects showed clinically relevant improvement (at least 2 points on the goal attainment scaling) in 11 goals. Testing the difference between all medians of baseline measurements (after correction for improvement during baseline) and the medians of the treatment phase measurements for all goal attainment scaling scores (n = 33) resulted in significant improvement (p < 0.001). Tested at subject level (medians of the three goal attainment scaling scores per assessment, n = 11), a significant improvement was also found (p = 0.005). The change in goal attainment scaling score was related to the moment of treatment with BTX-A. CONCLUSION: Clinically relevant improvement in individual rehabilitation goals at ability level, achieved with the treatment of BTX-A in children with cerebral palsy, were demonstrated using the goal attainment scaling method.     

Making geriatric assessment work: selecting useful measures

Often the goal of physical therapy is to reduce morbidity and prevent or delay loss of independence. The purpose of this article is to describe issues to consider when selecting measures of physical function for use with community-dwelling older adults over the age of 65 years. We chose 16 measures of physical function for review because they have been used in studies of community-dwelling older adults and some psychometric properties of reliability and validity have been described in the literature. Three major issues are discussed: (1) appropriateness of the measure for community-dwelling adults, (2) practical aspects of test administration, and (3) psychometric properties. These issues are illustrated using examples from the 16 measures. Two scenarios, applying the measures to the assessment of community-dwelling well older people and to the assessment of community-dwelling frail older people, are used to illustrate how this information can be used.     

Rehabilitation outcomes after brain injury: disability measures or goal achievement?

BACKGROUND: The outcome of rehabilitation interventions following brain injury is commonly rated by disability scales. Goal-setting and achievement are important in inpatient rehabilitation, but seldom assessed as outcomes. OBJECTIVE: To compare the information acquired from using disability ratings and goal attainment/variances as outcome measures in brain injury rehabilitation. SETTING: An inpatient regional neurological rehabilitation unit. SUBJECTS: One hundred and seventy-seven patients admitted after single incident brain injury over a three-year period. MAIN MEASURES: (1) Disability outcomes by the Barthel Index and the Functional Independence Measure, (2) goal achievement and variance distribution, and (3) the influence of diagnosis and demographics on these measures. RESULTS: Patients improved significantly on all disability scales employed (p < 0.0001), with the baseline admission scores being inversely correlated with changes in dependency by discharge (rho approximately -0.4). The median attainment rate of long-term goals was 75% per patient. Nonachievement was most frequently due to cognitive problems (38%), followed by behavioural difficulties and physical limitations (18% each). Goal achievement correlated poorly with disability outcome at discharge (rho < 0.3). Patients who accomplished all their goals tended to be less disabled at admission. Diagnostic groups and demographic factors had little influence on either disability or goal achievement outcomes. CONCLUSIONS: The use of a simple goal achievement and variance coding scheme has been relatively straightforward to incorporate into the daily practice of the unit. It provides useful information on rehabilitation process and outcome after brain injury that is complementary to the utilization of disability measures.     

Goal planning: a retrospective audit of rehabilitation process and outcome

OBJECTIVE: To consider the effectiveness of a goal planning programme for people with spinal cord injury (SCI) and address some of the current evidence gaps in goal setting. DESIGN: Retrospective audit. SUBJECTS: Consecutive series of 65 newly injured SCI patients. MAIN OUTCOME MEASURES: The Needs Assessment Checklist (NAC) has been specifically developed for the SCI population, and is used to assess patient attainment in core rehabilitation areas. A 'Goal Planning Progress' form was also used to specifically detail the goal planning process. RESULTS: Across the 65 patients, 396 goal planning meetings were held with 6176 goals set in total. Seventy-two per cent of the goals set at the first goal planning meeting were achieved by the second meeting. The rate of achievement at subsequent meetings was 68%. Significant differences in the number of planned rehabilitation days, number of goal planning meetings, and goals set were identified between injury categories. Significant positive correlations were found between the number of goals set and achievement, as measured by the NAC, in certain rehabilitation domains. CONCLUSIONS: The findings of this study demonstrate that the Needs Assessment and Goal Planning framework is effective in planning SCI rehabilitation. The capacity of this goal planning system to reflect individual need has also been established. Further systematic analyses of this process could potentially lead to more efficient rehabilitation and the identification of care pathways within clinical areas.     

A systematic review of the Human Activity Profile

OBJECTIVE: To review the measurement properties (reliability, validity, responsiveness) of the Human Activity Profile (HAP), a self-report measure of energy expenditure or physical fitness. DATA SOURCES: MEDLINE, CINAHL and EMBASE were searched up to September 2005 and the reference lists of included studies were checked for additional relevant studies. REVIEW METHOD: Studies were included that reported Human Activity Profile scores, test-retest reliability, correlations with other measures, or responsiveness (sensitivity to change). Of 83 potentially relevant articles, 39 articles were included plus the test manual. Two independent reviewers extracted data from the included studies. RESULTS: The Human Activity Profile has been used to evaluate physical activity in a wide variety of clinical populations and in healthy individuals. The change in score required to be 90% confident that change is beyond measurement error was estimated to be 7.8 for the Maximum Activity Score and 6.8 for the Adjusted Activity Score. The construct validity of the Human Activity Profile was supported by a large number of studies, although evidence for criterion validity was limited to four studies. No studies have investigated a priori the responsiveness or minimum clinically important difference of the Human Activity Profile. CONCLUSION: The Human Activity Profile appears to be a useful indicator of physical activity levels in people with chronic pain, arthritis, renal failure, various neurological and cardiorespiratory conditions, as well as in healthy older people.     

A Goal Attainment Pain Management Program for Older Adults with Arthritis

The purpose of this study was to test a pain management intervention that integrates goal setting with older adults (age ≥65) living independently in residential settings. This preliminary testing of the Goal Attainment Pain Management Program (GAPMAP) included a sample of 17 adults (mean age 79.29 years) with self-reported pain related to arthritis. Specific study aims were to: 1) explore the use of individual goal setting; 2) determine participants' levels of goal attainment; 3) determine whether changes occurred in the pain management methods used and found to be helpful by GAPMAP participants; and 4) determine whether changes occurred in selected pain-related variables (i.e., experience of living with persistent pain, the expected outcomes of pain management, pain management barriers, and global ratings of perceived pain intensity and success of pain management). Because of the small sample size, both parametric (t test) and nonparametric (Wilcoxon signed rank test) analyses were used to examine differences from pretest to posttest. Results showed that older individuals could successfully participate in setting and attaining individual goals. Thirteen of the 17 participants (76%) met their goals at the expected level or above. Two management methods (exercise and using a heated pool, tub, or shower) were used significantly more often after the intervention, and two methods (exercise and distraction) were identified as significantly more helpful. Two pain-related variables (experience of living with persistent pain and expected outcomes of pain management) revealed significant change, and all of those tested showed overall improvement.     

Goal setting in palliative care: A structured review

Abstract

Background

Palliative care and rehabilitation both aim to support patients to live as actively as possible. Goal setting has been identified in health policy and clinical guidelines as a mechanism to achieve this. While goal setting is well established in traditional rehabilitation, it is unclear how it should be implemented within palliative care where people are faced with diminishing abilities.

Aim

To identify and synthesize published literature regarding goal setting in palliative care.

Method

Electronic searches were carried out on MEDLINE, PSYCHINFO, EMBASE, CINAHL, ASSIA, and Google Scholar databases between November 2010 and January 2011. Papers were included if they focused on patient-centred goal setting in palliative care. No restrictions were placed on study design or type of paper. Papers were classified according to the type and design and research papers were quality appraised. Papers were read and analysed using framework analysis.

Findings

Sixteen papers met the inclusion criteria. Three themes were identified: 1. Definitions, process, and functions of goal setting;

2. The challenges of delivering goal setting;

3. Theories underpinning goal setting.

Conclusions

Goal setting is recognized as an important component of patient-centred palliative care, but there is no agreement regarding ‘best practice’ and clinicians face particular challenges when trying to set goals with patients in this context. Little attention has been paid to developing a robust, theory-based approach to goal setting in this setting. Hope theory and theories of how people adapt to life-threatening illness could inform the process of goal setting in palliative care.     

Goal setting practice in services delivering community-based stroke rehabilitation: a United Kingdom (UK) wide survey

Abstract

Purpose: We investigated the nature of services providing community-based stroke rehabilitation across the UK, and goal setting practice used within them, to inform evaluation of a goal setting and action planning (G-AP) framework. Methods: We designed, piloted and electronically distributed a survey to health professionals working in community-based stroke rehabilitation settings across the UK. We optimised recruitment using a multi-faceted strategy. Results: Responses were analysed from 437 services. Services size, composition and input was highly variable; however, most were multi-disciplinary (82%; n?=?335/407) and provided input to a mixed diagnostic group of patients (71%; n?=?312/437). Ninety one percent of services (n?=?358/395) reported setting goals with “all” or “most” stroke survivors. Seventeen percent (n?=?65/380) reported that no methods were used to guide goal setting practice; 47% (n?=?148/315) reported use of informal methods only. Goal setting practice varied, e.g. 98% of services (n?=?362/369) reported routinely asking patients about goal priorities; 39% (n?=?141/360) reported routinely providing patients with a copy of their goals. Conclusions: Goal setting is embedded within community-based stroke rehabilitation; however, practice varies and is potentially sub-optimal. Further evaluation of the G-AP framework is warranted to inform optimal practice. Evaluation design will take account of the diverse service models that exist.

• Implications for Rehabilitation

• Community-based stroke rehabilitation services across the UK are diverse and tend to see a mixed diagnostic group of patients.

• Goal setting is implemented routinely within community-based stroke rehabilitation services; however, practice is variable and potentially sub-optimal.

• Further evaluation of the G-AP framework is warranted to assess its effectiveness in practice.

     

A measure of neurobehavioral functioning after coma. Part II: Clinical and scientific implementation

This is a longitudinal validation study that is Part II of a two-part series. Part I focuses on the methods used to construct the neurobehavioral measure derived from the Disorders of Consciousness Scale (DOCS) as well as the evidence of reliability and validity. Part II illustrates, through a series of selected case reports, the clinical use of repeated DOCS measures to enhance and complement medical rehabilitation management. The use of repeated DOCS measures in scientific investigations of mechanisms of injury is also described. Participants included patients at rehabilitation hospitals who were 18 years of age and older and unconscious after severe brain injury. Medical decision making regarding short-term effects of pharmacological intervention was augmented and improved through the examination of individual neurobehavioral recovery patterns. We identified medications to treat secondary medical complications and successfully determined effective dosage, presumably improving prognosis for recovery. We facilitated and enhanced development and refinement of individualized rehabilitation programs. Two investigations of treatment effectiveness during coma recovery and examination of the relationship between behavioral changes and neural adaptation are also described. By systematically tracking and mapping individual patterns of neurobehavioral recovery, we show that medical and rehabilitation management after coma can be enhanced. In addition, we also show that by examining the relationship between the DOCS neurobehavioral measure with mechanistic indicators of neurological recovery such as functional magnetic resonance imaging, scientific investigations of treatment and rehabilitation effectiveness can be enhanced.     

Goal attainment scaling as a method of clinical service evaluation

The demand for clinical accountability and the documentation of therapeutic effectiveness continues to increase in health-related settings. Therapists are attempting to address this increasing demand by adapting methods based on traditional experimental models of research to evaluate their clinical practice. Experimental and quasi-experimental designs, however, are often limited usefulness in clinical environments for a variety of practical and ethical reasons. This paper presents a method of evaluating the effectiveness of a therapeutic intervention called goal attainment scaling, which involves goal setting procedures and assessment techniques that are practice-based and practitioner-oriented. The procedures are presented and the argument made that goal attainment scaling is a viable method by which one can document therapeutic change and demonstrate clinical accountability.     

Development and validation of a new instrument for testing functional health literacy in Japanese adults

This study aimed to develop a reliable and valid measure of functional health literacy in a Japanese clinical setting. Test development consisted of three phases: generation of an item pool, consultation with experts to assess content validity, and comparison with external criteria (the Japanese Health Knowledge Test) to assess criterion validity. A trial version of the test was administered to 535 Japanese outpatients. Internal consistency reliability, calculated by Cronbach's alpha, was 0.81, and concurrent validity was moderate. Receiver Operating Characteristics and Item Response Theory were used to classify patients as having adequate, marginal, or inadequate functional health literacy. Both inadequate and marginal functional health literacy were associated with older age, lower income, lower educational attainment, and poor health knowledge. The time required to complete the test was 10–15 min. This test should enable health workers to better identify patients with inadequate health literacy.     

Standardized outcome assessment in brain injury rehabilitation for younger adults

Purpose: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. Method: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability - they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM+FAM). The relationship between these instruments is discussed. Conclusion: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.     

A preliminary reliability and validity study of the Chinese version of the self-efficacy for exercise scale for older adults

Background

Population ageing affects most undeveloped, developing and developed countries. Less than a quarter of older people undertake a level of physical activity worldwide that is sufficient to lead to health benefits. Understanding older people’s confidence regarding engaging in exercise helps to structure physical activity interventions that motivate them to initiate and adhere to regular exercise. Estimates of the reliability and validity of the English version of the self-efficacy for exercise (SEE) scale has been widely tested and shown to be valid for use in various settings and among older people. The reliability and validity of a Chinese version of the SEE for older adults has not been tested.

Aim

To undertake a preliminary assessment of the reliability and validity of the SEE scale when applied to the older Chinese adults.

Methods

The Chinese version of the self-efficacy for exercise (SEE-C) scale was tested on a sample of 192 older people from Taiwan with a mean age of 71.2 years recruited between October and December 2003.

Results

There was acceptable internal consistency of the SEE-C scale. The fit of the measurement model to the data for the SEE-C scale was acceptable. There was evidence of validity of the measure based on hypothesis testing: health status predicted exercise self-efficacy, and exercise self-efficacy predicted physical activity. Those who exercised regularly (n = 102) had a higher mean SEE-C score (5.3) than those who did not (2.9, n = 90).

Conclusion

This preliminary validation study provided evidence for the reliability and validity of the Chinese version of the SEE scale. Future testing of the SEE-C scale needs to be carried out to see whether these results are generalisable to older Chinese people living in urban areas and with different characteristics. A test of the scale among younger adults for a wider use of the instrument is also warranted.     

Standardized outcome assessment in brain injury rehabilitation for younger adults

Purpose: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. Method: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability - they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM+FAM). The relationship between these instruments is discussed. Conclusion: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.     

Validation of a new lower-extremity motor coordination test

OBJECTIVE: To determine the test-retest reliability and construct validity of a new lower-extremity motor coordination test, the Lower Extremity MOtor COordination Test (LEMOCOT). DESIGN: To test reliability, subjects with impairments in at least 1 lower extremity were evaluated twice by the same evaluator. To test construct validity, the LEMOCOT scores obtained from subjects who had had a stroke were correlated with physical, functional, cognitive, and perceptual tests. SETTING: Geriatric day hospital and functional intensive rehabilitation unit. PARTICIPANTS: In the reliability test, 29 people (mean age, 69.6y; range, 28-87y); in the construct validity, 144 people who recently had had a stroke. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: In addition to the LEMOCOT, the following measures were used for construct validity: the Fugl-Meyer Assessment (motor function), Berg Balance Scale, 5-m walking test, 2-minute walking test, Functional Autonomy Measurement System, Modified Mini-Mental State Examination, and Motor-Free Visual Perceptual Test. RESULTS: Intraclass correlation coefficients (ICCs) indicated that test-retest reliability is good (right-side ICC=.88; left-side ICC=.83). The construct validity of the LEMOCOT was demonstrated by obtaining high correlations with physical and functional tests ( r range, .62-.79; P <.001) and no correlations with cognitive ( r =.11, P =.20) or visual perceptual tests ( r =.15, P =.08) and by discriminating between subjects discharged to long-term care versus other living environments ( P <.001). CONCLUSIONS: The LEMOCOT is a simple lower-extremity motor coordination test that showed good test-retest reliability and construct validity. It can be used in clinical and research settings, specifically with people who have had a stroke. Other studies should be carried out to confirm its psychometric properties.     

Development of the Brunel Balance Assessment: a new measure of balance disability post stroke

OBJECTIVE: To report the psychometric properties of the Brunel Balance Assessment (BBA), a new test of balance disability post stroke. DESIGN: Data from 92 subjects were collected and cohorts used to test hierarchical scaling, reliability and validity. Data from 80 people were used to test the hierarchical scaling using an inter-item correlation for redundancy, coefficient of reproducibility (CR) and scalability (CS) for the hierarchy and Cronbach's alpha coefficient for the internal consistency. Thirty-seven people participated in the reliability testing. Test-retest and inter-tester reliability were tested using the kappa coefficient. The testing was repeated on consecutive days to assess test-retest reliability and was scored simultaneously by two physiotherapists for inter-tester reliability. Fifty-five people participated in validity testing. The BBA was compared with the sitting Motor Assessment Scale (MAS), Berg Balance Test (Berg), Rivermead Mobility Index (RMI) using Spearman's rho. SETTING: Physiotherapy stroke services of six UK NHS trusts. PARTICIPANTS: Hemiplegic stroke patients were recruited from physiotherapy services and the BBA used to assess their balance. RESULTS: The order of the items was revised and the original 14-point scale reduced to 12 points in the scale development. The revised scale formed a hierarchical scale. Inter-item correlations were < 0.9, coefficients of reproducibility and scalability were 0.99 and 0.69 respectively and Cronbach's alpha was 0.92. Reliability was high (100% agreement) for both aspects of reliability. Correlations with other balance measures were significant (0.83-0.97, p < 0.01) indicating validity as measure of balance disability. CONCLUSION: The BBA is a reliable, valid, hierarchical measure of balance disability post stroke that is suitable for use in the clinical setting.     

The Community Balance and Mobility Scale--a balance measure for individuals with traumatic brain injury

OBJECTIVE: To provide evidence for the validity and reliability of a new outcome measure of balance, the Community Balance and Mobility Scale, developed for the ambulatory individual with traumatic brain injury. DESIGN: A validity and reliability study. SETTING: Acute care, in- and outpatient rehabilitation and day hospital settings. SUBJECTS: Two convenience samples (n=36, 32) of ambulatory patients with traumatic brain injury. MAIN MEASURES: The content and construct validity, test-retest, inter- and intra-rater reliability and internal consistency of the Community Balance and Mobility Scale. RESULTS: Content validity was demonstrated by the involvement of patients with traumatic brain injury (n=7) and clinicians (n=17) in the process of item generation and by physical therapists' ratings of item relevance. Further support is the correlation of the Community Balance and Mobility Scale scores with physical therapists' global balance ratings of the patient (r=0.62). Construct validity was supported by the ability of the measure to differentiate between patients along the continuum of care and also by comparisons with maximal walking velocity (r=0.64). Patients who scored greater than or less than 50 on the balance measure demonstrated significantly different Community Integration Questionnaire scores (P=0.004). The Community Balance and Mobility Scale demonstrated intraclass correlation coefficients (ICCs) of 0.977, 0.977, 0.975 and Cronbach's alpha of 0.96 for intra-, inter-, test-retest reliability and internal consistency, respectively. CONCLUSION: The Community Balance and Mobility Scale is a valid and reliable outcome measure for the ambulatory individual with traumatic brain injury.