Goal Setting in Rehabilitation

Original Editor - Lauren Lopez Top Contributors - Lauren Lopez, Tony Lowe, Naomi O'Reilly, Amanda Ager and Claire Knott

Original Editor - Your name will be added here if you created the original content for this page.

Top Contributors - Lauren Lopez, Tony Lowe, Naomi O'Reilly, Amanda Ager and Claire Knott  

Introduction

Goal setting between physiotherapists / physical therapists and their patients or clients is a fundamental part of rehabilitation. It is “the formal process whereby a rehabilitation professional or a multidisciplinary team, together with the patient and/or their family, negotiate goals.”[1]   

Goal setting is used to direct rehabilitation interventions towards a specific outcome or outcomes, and can result in greater client satisfaction and improved recovery.  Shared goal setting can also co-ordinate members of the multidisciplinary team and ensure they are working together towards a common goal and that nothing important is missed.[1] Goals can also be used to evaluate the success of rehabilitation interventions.[1] 

There is no consensus on a gold standard for a method of goal setting, but it is widely held that it is a priority for guiding rehabilitation interventions toward achievable and meaningful outcomes.[1] There is a growing body of literature dedicated to the methods of, and evidence for,[1][2][3] goal setting in rehabilitation. 

The Basics of Goal Setting

Goal setting is based on the belief that humans can change their behaviour and work towards a goal[4]. Goal setting is important for rehabilitation because it can provide the patient with motivation[1], particularly when they are functional and directly relate to real life activities. A meaningful goal can maximise patient engagement and motivate a patient to participate in rehabilitation in order to achieve their goals.  For example, the elderly patient in rehabilitation following a hip replacement who wants to return to living independently in their own home with their spouse. In order to do this, the patient needs to be independently mobile and therefore can see the importance of participating in physiotherapy. 
Diagram One: Maslow's Hierarchy of Needs
Maslow's Hierarchy of Needs
Goals can be thought of as hierarchical[5]. Maslow suggested that a person will make their physiological needs their primary goals. Once a person has met their physiological needs, he or she will make goals at the next level, safety and security, and so on.      

Goal setting is also important as it keeps the focus of rehabilitation patient-centred. Goal setting helps health professionals plan their interventions for what is best or most meaningful for the patient instead of what suits the health professionals (where there are differences).  

Goals can be defined by time e.g. short, medium or long-term. In physiotherapy, goals are often activity based. For example, a patient being able to do a functional task independently or being able to walk a certain distance with the aid of walking frame. 

Goal Setting Methods

Goal setting is the process of discussing, planning and documenting outcomes for a patient or client. It can be as simple as a conversation between a physiotherapist / physical therapist and a patient during a treatment session. Or, in can be more complex and structured in a meeting between a multidisciplinary team and a patient. The patient’s social supports, e.g family members or friends, may also be invited to join in with goal setting if they have a role to play in helping the patient achieve a particular goal.    

SMART Goals

One common method of goal setting has been derived from SMART goals. SMART goals originated in the field of project management.[6] There are some variations, but it is generally accepted that the acronym stands for: 

S   Specific 

M  Measurable 

A   Attainable or Assignable 

R   Realistic 

T   Time-related    

Goal Attainment Scaling

Another system which is grounded in rehabilitation research is the Goal Attainment Scaling (GAS) by Turner-Stokes.[7] GAS is “a mathematical technique for quantifying the achievement of goals”.[7] GAS describes a process for setting goals and uses a five-point scale to measure if the goal is achieved or not. GAS scores can then be aggregated. Individual scores can be weighted to reflect either the relative importance of a goal to the patient or health professional or the difficulty in achieving the goal.

Ask Questions

Questions are a good way of starting the goal setting process. The following questions from The Learning Corp[8] may help.

  • What can’t you do since your injury that you want to get back to?
  • What are you finding more difficult since your injury that you’d like to be easier?
  • How will you know when you’re ready to stop coming to see me?

Using the person's responses to these questions, the clinician can help form them into SMART, concrete goals. Also of importance, is defining the goals in an active, first-person manner e.g. "I will do..."[8].

Examples of Goal Setting

The table below is from The Learning Corp[8] and is an excellent demonstration of taking initial statements from the patient or client and turning them into practical, measurable goals.

Initial Goal Statement More Functional & Meaningful Real-World Goal Statement Turning The Functional Goal Statement Into A SMART Goal Example Of Evidence-Based Therapy Tasks Which Can Help
Talk Better “I want to participate in the dinner table conversation with my family.” On 4 out of 7 nights this week, I will use my word-finding strategies at the dinner table to share 3 things that happened to me that day. All Speaking tasks, for example:

Name Pictures & Name Verbs.

Be Able to Follow Directions “I want to bake with my grandkids.” On Saturday I will use strategies (e.g. note-taking, verbal mediation, planning) to follow a 6-step brownie recipe with 95% accuracy. Instruction Sequencing
Improve Memory “I want to remember to take my morning pills without a reminder from my spouse.” On 5 out of 7 days this week, I will use my memory strategies to independently take my medicine every morning at 8 a.m. All Visual Memory Tasks and Auditory Memory Tasks are relevant. For example: Repeat Number Sequences and Picture N-Back Memory
Be Able to Read “I want to read to my son at bedtime.” On 3 out of 7 nights this week, I will read a short storybook to my son. Read Active Sentences AloudRead Passive Sentences AloudRead Number Sequences Aloud
Not Get So Distracted “I want to watch my daughter’s soccer game without getting distracted.” On Sunday I will use my strategies to attend to my daughter’s soccer game for 20 min without getting distracted. Playing Card SlapjackSpoken Word N-Back Memory
Not Get Lost In New Places “I want to walk around the town without getting lost.” This week I will map out the route to town & walk there 3 times without getting lost. Map Reading
Be Able To Write “I want to write in my journal again.” “On 3 out of 7 nights this week, I will write 2 complete sentences in my journal. Picture Spelling
Get My Math Skills Back “I want to return to paying for things when I go out with my family.” When I go out to lunch with my family tomorrow, I will use strategies (e.g. note-taking, slowing down, double-checking work) to accurately calculate the tip on the bill. CurrencySpeak CurrencyFunctional Math

Measuring Goals

Measuring person-centred goals is a helpful way to measure outcomes in rehabilitation, particularly patient satisfaction with their performance of a specific goal[8]. Sometimes a person's goals may not seem realistic to the clinician, or, the person not achieve their goals. Instead of regarding this as failure, the unachieved goals can be used for a discussion about what might be a realistic outcome for the person's rehabilitation and to guide challenging discussions on expectations versus reality. Additionally, the unachieved goal could be broken down into smaller, more achievable parts[8].

As above, GAS is another way to measure goals.

Influences on Goal Setting

There are some factors which can facilitate or create barriers to successful goal setting, see Table 1 below.   

Table 1: Factors Influencing Goal Setting

Factor Influence  Evidence 
Time  Facilitator or barrier  [9] 
Social supports  Family and friends may help or hinder  [10] 
Pain  Barrier  [10] 
Health professionals’ expertise or lack of  Facilitator or barrier  [9][11] 
Cognition  Barrier  [3] 
The patient’s self awareness  Facilitator or barrier  [12] 
Patient involvement  Facilitator or barrier  [11][13][14] 
Patient’s desire to pursue goals and modify as needed  Facilitator  [15] 

Evidence For Goal Setting

Author  Date  Population  N=  Intervention  Outcome Measure  Main Results 
Bouwens et al  2009  Acquired brain injury  48  Cognitive rehabilitation programme  Goal Attainment Scaling, number of goals made, time to set goals, domains in which goals were set   It is possible to set three realistic goals per patient within 30 minutes. Goals were set in cognitive and behavioural domains 
Rosewilliam et al  2011  Stroke  N/A  Systematic review of 18 qualitative studies, eight quantitative studies and one mixed methods study  N/A  Nominal adoption of goals setting, discrepancies between perceptions and practice of goal setting, related ethical conflicts, strategies to improve goal setting, weak methodologies, some improvement in psychological outcomes, further research needed. 
Coffey et al  2014  Lower limb amputation  64  Not applicable  WHODAS 2.0, WHO-QOL-BREF, 

Tenacious Goal Pursuit Scale, Flexible Goal Adjustment Scale 

High levels of disability in this population. QoL stable over first six months. Stronger goal pursuit and goal adjustment tendencies predicted lower disability and higher QoL six months post discharge 
Alanko et al  2018  Stroke and back pain  20  Not applicable  Qualitative  interviews and analysis of rehabilitees perspectives on goal setting in rehabilitation  Five meanings: 

1) “trust in the rehabilitation situation, professionals, oneself and relatives” 

2) “respectful presence” 

3) “confusing awareness” 

4) “disturbing pain” 

5) “fear of unpredictability” 

Practical Points to Remember

  • Use goals to guide and evaluate your physiotherapy treatments. 
  • Discuss, plan and review goals for rehabilitation with your patient. 
  • Discuss, plan and review goals for rehabilitation with other members of your multidisciplinary team (if applicable). 
  • Use a method such as SMART or GAS, and document the goals made with a date to review them and check for progress.
     

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Wade P. Goal setting in rehabilitation: an overview of what, why and how. Clin Rehabil. 2009 Apr;23(4):291-5 http://journals.sagepub.com/doi/abs/10.1177/0269215509103551 (accessed 20 July 2018)
  2. Rosewilliam S, Roskell CA, Pandyan AD. A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation. Clin Rehabil. 2011. 25(6): 501-514. Available from http://journals.sagepub.com/doi/abs/10.1177/026921551039446725, Issue 6, pp. 501 - 514. Accessed 28 June 2018. 
  3. 3.0 3.1 Bouwens SFM, van Heugten CM, Verhey FRJ. The practical use of goal attainment scaling for people with acquired brain injury who receive cognitive rehabilitation. Clin Rehabil 2009 23 (4):310 - 320. http://journals.sagepub.com/doi/abs/10.1177/0269215508101744 (accessed 17 July 2018).
  4. Scobbie L, Wyke S, Dixon D. Identifying and applying psychological theory to setting and achieving rehabilitation goals: development of a practice framework. Clin Rehabil 2009; 23 (4): 321-333. ISSN 0269-2155. https://strathprints.strath.ac.uk/20128/ (accessed 17 July 2018).
  5. Maslow AH. A Theory of Human Motivation. Originally published in Psychological Review 1943; 50, 370-396. Accessed from Green, CD. Classics in the History of Psychology [Internet] 2000https://psychclassics.yorku.ca/Maslow/motivation.htm (accessed 25 July 2018).
  6. Doran GT. There’s a S.M.A.R.T. Way to Write Management’s Goals and Objectives. Management Review. 1981; 70: 35-36.https://community.mis.temple.edu/mis0855002fall2015/files/2015/10/S.M.A.R.T-Way-Management-Review.pdf (accessed 25 July 2018).
  7. 7.0 7.1 Turner-Stokes L. Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clin Rehabil. 2009; 23 (4); 362-370. http://journals.sagepub.com/doi/abs/10.1177/0269215508101742 (accessed 26 July 2018).
  8. 8.0 8.1 8.2 8.3 8.4 The Learning Corp. More successful brain rehabilitation: turning therapy goals into real-life activities.10 October 2018. Available from: https://thelearningcorp.com/brainwire/targeting-more-successful-recovery-turning-therapy-goals-into-real-life-activities/#ppm21717 (accessed 28 October 2019).
  9. 9.0 9.1 Playford ED, Siegert R, Levack W, Freeman J. Areas of consensus and controversy about goal setting in rehabilitation: a conference report. Clin Rehabil. 2009. 23(4): 334-344.http://journals.sagepub.com/doi/abs/10.1177/0269215509103506. Accessed 27 June 2018. 
  10. 10.0 10.1 Alanko T, Karhula M, Kröger T, Piirainen A, Nikander R. Rehabilitees perspective on goal setting in rehabilitation – a phenomenological approach. Disabil Rehabil. 2018. DOI: 10.1080/09638288.2018.1463398. Published online at https://www.tandfonline.com/doi/abs/10.1080/09638288.2018.1463398.
  11. 11.0 11.1 Plant SE, Tyson SF, Kirk S, Parsons J. What are the barriers and facilitators to goal-setting during rehabilitation for stroke and other acquired brain injuries? A systematic review and meta-synthesis. Clin Rehabil. 2016. 30(9): 921-930. Available from http://journals.sagepub.com/doi/pdf/10.1177/0269215516655856. Accessed 27 June 2018. 
  12. Fischer S, Gauggel S, Trexler LE. Awareness of activity limitations, goal setting and rehabilitation outcome in patients with brain injuries, Brain Inj. 2004;18:6, 547-562. https://www.tandfonline.com/doi/abs/10.1080/02699050310001645793 (accessed 25 July 2018).
  13. Evans JJ. Goal setting during rehabilitation early and late after acquired brain injury. Curr Opin Neurol. 2012;25(6):651-5. https://www.ncbi.nlm.nih.gov/pubmed/23007008 (accessed 25 July 2018).
  14. Barnard RA, Cruice, MN, Playford ED. Strategies Used in the Pursuit of Achievability During Goal Setting in Rehabilitation.  Qual Health Res. 2010. 20(2): 239-250. Available from http://journals.sagepub.com/doi/abs/10.1177/1049732309358327 
  15. Coffey L, Gallagher P, Desmond D. Goal Pursuit and Goal Adjustment as Predictors of Disability and Quality of Life Among Individuals With a Lower Limb Amputation: A Prospective Study. Arch Phys Med Rehabil. 2014; 95 (2): 244-252.https://www.sciencedirect.com/science/article/pii/S0003999313006230 (accessed 29 July 2018).