Clinical Rehabilitation

Objective: To determine the acceptability and clinical application of two recently developed goal-setting interventions (Goal Management Training and Identity Oriented Goal Training) in people with traumatic brain injury.

Design: A three parallel group, randomized controlled pilot study.

Setting: Inpatient and community rehabilitation facilities.

Subjects: Thirty-four people with moderate to severe traumatic brain injury (Goal Management Training, n = 12; Identity Oriented Goal Training, n = 10; usual care, n = 12) and their rehabilitation clinicians.

Interventions: For both Goal Management Training and Identity Oriented Goal Training participants met face to face with their key worker weekly over a period of 6—8 weeks, during which time the key worker worked to engage them in goal setting and goal performance using the strategy prescribed by their group allocation. Usual care was provided to the other participants.

Main measures: Largely qualitative using observation, individual interviews and focus groups. Participants also completed a Goal Attainment Scale at baseline, post intervention and at three months follow-up.

Results: Both approaches were acceptable to the majority of participants with many reporting improved mood and goal attainment. Clinicians found working in a different way with patients both challenging and rewarding, with both experimental approaches enhancing a focus on the person's own goals. Identity Oriented Goal Training seemed particularly helpful in engaging people in the goal-setting process while Goal Management Training appeared particularly helpful in providing a structured framework for error prevention in attempting goal performance.

Conclusion: These theoretically informed approaches to goal setting showed promise but were time intensive and at times difficult for practitioners to utilize.

Objective: To examine the feasibility of and clinical experiences with goal attainment scaling when used for the evaluation of cognitive rehabilitation in people with acquired brain injury.

Design: A prospective observational longitudinal study.

Setting: A 21-week cognitive rehabilitation programme and a cognitive programme with varying length in two different Dutch rehabilitation centres.

Subjects: Forty-eight consecutive patients with acquired brain injury enrolled during a 15-month period.

Interventions: Cognitive rehabilitation programme.

Main measure: Goal attainment scaling; the number of goals was counted; time to set goals was recorded; the number of different domains in which goals were set was counted; goal attainment scaling score was calculated at baseline, one week after the end of the cognitive rehabilitation programme and at six months follow-up; clinical experiences that could be useful for both clinical and research practice were recorded.

Results: The mean (SD) age of the patients was 46.1 (10.7) years; 29 (60%) were male; 186 goals were set with a mean (SD) number of 4 (1) goals per patient. It was possible to set at least three realistic goals per patient within 30 minutes. Most goals were set in the cognitive domain (i.e. memory and attention), followed by the behavioural domain (i.e. fatigue and aggression).

Conclusion: It proved possible to set three goals within an acceptable time-frame, to involve patients in the goal-setting procedure, to set realistic goals, and to set goals within relevant domains. Based on clinical experiences, goal attainment scaling is less feasible for research when patients lack insight, or suffer from comorbidity or mood problems.

Background: Goal setting is considered to be a fundamental part of rehabilitation; however, theories of behaviour change relevant to goal-setting practice have not been comprehensively reviewed.

Objectives: (i) To identify and discuss specific theories of behaviour change relevant to goal-setting practice in the rehabilitation setting. (ii) To identify `candidate' theories that that offer most potential to inform clinical practice.

Methods: The rehabilitation and self-management literature was systematically searched to identify review papers or empirical studies that proposed a specific theory of behaviour change relevant to setting and/or achieving goals in a clinical context. Data from included papers were extracted under the headings of: key constructs, clinical application and empirical support.

Results: Twenty-four papers were included in the review which proposed a total of five theories: (i) social cognitive theory, (ii) goal setting theory, (iii) health action process approach, (iv) proactive coping theory, and (v) the self-regulatory model of illness behaviour. The first three of these theories demonstrated most potential to inform clinical practice, on the basis of their capacity to inform interventions that resulted in improved patient outcomes.

Conclusions: Social cognitive theory, goal setting theory and the health action process approach are theories of behaviour change that can inform clinicians in the process of setting and achieving goals in the rehabilitation setting. Overlapping constructs within these theories have been identified, and can be applied in clinical practice through the development and evaluation of a goal-setting practice framework.

Objective: To consider clinical issues surrounding goal setting in neurological rehabilitation, and to identify priorities for future research.

Participants: Twenty-four rehabilitation professionals were invited to attend because they had taught or published on the topic of goal setting. In addition two patient groups were represented.

Evidence: (1) The results of a systematic literature review, (2) presentations given during the two-day conference by investigators working within the field of goal setting, (3) questions and statements from conference attendees during open discussion, (4) a report initially formulated by a panel composed of four of the conference attendees, and then circulated to all attendees for comment, (5) views of the conference attendees gathered using a modified Delphi technique.

Consensus: There were significant areas of consensus about goal setting. The Delphi studies highlighted and confirmed these areas of general agreement with consensus that goal setting is a core component of the rehabilitation process, and that goals should be specific, ambitious, relevant and time limited, with incremental steps that lead to progressive achievement. It was also agreed that that goal setting has a major impact on the relationship between patient and professional, with the availability of professional time and expertise being key to the success of the process.

Controversy: Areas in which there was more controversy centred on the evaluation of goal achievement and the benefits of ambitious rather than achievable goals. The need for patient-centred goal setting was recognized, although it was felt at times that there were conflicts that prevented this being attainable.

Background: Past debate on ethics in goal planning for rehabilitation has tended to focus on tensions that can arise between ethical principles; in particular the principles of autonomy and beneficence. When setting goals, clinicians tend to prioritize the wishes of patients, justifying this from the perspective of maximizing patient autonomy. This is tempered by consideration of what is `realistic' and what the pursuit of `unrealistic goals' might be on patient well-being.

Rationale: In this paper it is argued that clinicians also have an ethical obligation to take into account the resource implications of goal planning. Utilitarianism provides one perspective on addressing such issues. A utilitarian approach to goal planning would necessitate a focus on maximizing the benefits of rehabilitation to the whole community served when negotiating goals with individual patients.

Critique: Clinicians may, however, have a number of concerns about utilitarianism. One assumption is that the quality of life of people with severe disability will be judged as being intrinsically low, and therefore valued less from a utilitarian perspective. A second assumption is that for people with severe disability the large effort expended in rehabilitation to achieve small gains cannot possibly repay itself in a utilitarian equation, specifically in financial terms. Evidence from the literature however has demonstrated that in fact both of these assumptions are probably false.

Conclusion: Rehabilitation professionals should not be hesitant to consider utilitarianism as an ethical framework for rehabilitation. In fact, rehabilitation may well gain if people were to use this approach.

Objective: To describe a practical method of setting personalized but specific goals in rehabilitation that also facilitates the use of goal attainment scaling.

Background: Rehabilitation is a complex intervention requiring coordinated actions by a team, a process that depends upon setting interdisciplinary goals that are specific, clear and personal to the patient. Goal setting can take much time and still be vague. A practical and standardized method is needed for being specific.

Method: A novel approach to writing specific, measurable, achievable, realistic/ relevant and timed (SMART) goals is developed here. Each goal can be built up by using up to four parts: the target activity, the support needed, quantification of performance and the time period to achieve the desired state. This method can be employed as part of goal attainment scaling and the other levels can be easily and quickly formulated by adding, deleting and/or changing one or more of the (sub)parts.

Discussion: The success of goal setting and goal attainment scaling depends on the formulation of the goals. The method described here is a useful tool to standardize the writing of goals in rehabilitation. It saves time and simplifies the construction of goals that are sufficiently specific to be measurable.

Goal attainment scaling is a mathematical technique for quantifying the achievement (or otherwise) of goals set, and it can be used in rehabilitation. Because several different approaches are described in the literature, this article presents a simple practical approach to encourage uniformity in its application. It outlines the process of setting goals appropriately, so that the achievement of each goal can be measured on a 5-point scale ranging from -2 to +2, and then explains a method for quantifying the outcome in a single aggregated goal attainment score. This method gives a numerical T-score which is normally distributed about a mean of 50 (if the goals are achieved precisely) with a standard deviation of around this mean of 10 (if the goals are overachieved or underachieved). If desired, the approach encompasses weighting of goals to reflect the opinion of the patient on the personal importance of the goal and the opinion of the therapist or team on the difficulty of achieving the goal. Some practical tips are offered, as well as a simple spreadsheet (in Microsoft Excel) allowing easy calculation of the T-scores.

Objective: To evaluate the effects of an exercise and education programme on primary outcomes of exercise efficacy and activity levels; and on secondary outcomes including quality of life, mood and physical disability.

Design: Randomized, single blind trial.

Setting: Specialist neurosciences centre.

Participants: Forty-four patients with acquired neurological pathologies. Interventions: Twenty-one participants undertook a four-week exercise and education programme alongside standard follow-up care. Twenty-three participants underwent standard follow-up care alone.

Outcome measures: Primary outcome measures included the Exercise Efficacy Scale and Human Activity Profile. Secondary outcomes were evaluated by the Short Form 36 Health Survey, Hospital Anxiety and Depression Scale, UWIST Mood Adjective Checklist, Motricity Index, Frenchay Arm Test, Rivermead Mobility Index, 10-metre timed walk and a visual analogue scale. Data were collected at baseline and at 6, 12 and 24 weeks.

Results: At six weeks, significant improvements in exercise efficacy were found following the treatment but not the control (P= 0.001). Moderate improvements in activity levels were noted for both study groups with no between-group differences. Short Form 36 `physical health' and `general health' domains showed trends towards increased positive change following the intervention, but these did not reach significant levels. Mood, physical impairment and physical disability remained unchanged within either study group. Longer term follow-up revealed that the improvements noted in exercise self-efficacy, activity levels and quality of life were maintained.

Conclusions: The intervention resulted in improved exercise efficacy and may positively influence the physical and general health dimensions of health-related quality of life.