Goal setting - If you're not assessing your guessing!

So this is the first blog on my updated site! I think the white background is much easier on the eyes!

With so much discussion and published research about making rehab more individual, patient centred, relevant and meaningful and this helping to improve the therapeutic relationships and outcome, I thought I would focus on one of the KEY things in this blog that I believe does that, GOAL SETTING! It is probably not quite as sexy as post about biomechanical stuff but equally as important.

If your not assessing your guessing is a pretty crapy term, as most of the time the assessments used can be pretty rubbish, but I don't think the rehab goals of someone are!

I mean how the hell are you meant to individualise care if you don’t know what the individual WANTS or NEEDS to do! Sometimes goals will be clearly defined, other times more digging is needed or maybe there is nothing specific, just being out of pain is enough. Like most things in rehab, goal setting probably exists on a spectrum from really simple goals to some exceptionally complex ones, but for some people finding out a bit more about what THEY want maybe a real big deal and can provide motivation, focus and direction. Ever had a patient or client who lacks those things??

Getting to people’s goals may not always happen through formal questioning but also in general interaction. This often happens with previous injury history where when formally asked someone forgets to tell you about the time they had their leg bitten off by a shark but casually drops it in during an exercise.

The traditional measures that are used during therapy often don’t capture either people’s goals or whether they are being achieved. This paper HERE found 27 individual goals that had NO relation to the traditional measures of pain, strength or ROM and this suggests that traditional clinical outcome measures might not be capturing whether treatment is meaningfully successful to the patient. This also asks the question of whether being pain free is enough for a successful outcome? We could remain pain free through avoiding the things we love to do but is this successful recovery? It is if you are only measuring pain!

Physical perspective

Any good physical programme should have an element of needs analysis that takes into consideration the demands of a desired activity and then how to achieve this through a rehab programme. For some, a basic exercise program may more than suffice, especially if currently sedentary, for others their needs maybe more specific with a clearly defined activity, sport or movement being problematic.

Effective individualised treatment can often be a blend of the more generic AND specific and this may also change at different stages of rehab. Would we suggest ACL rehab without change of direction or hamstring rehab without high speed running or eccentrics? These elements are both SPECIFIC to the needs of the sports that these types of injuries often occur in and are required for return to play. Potentially we view these types of injuries differently to more persistent pain where functionality often seems secondary to the pain itself and goals, such as return to play, are not so clearly defined. Goal setting like EVERYTHING, is not required for everybody. For a runner, goal setting might not be a necessary process, you would know that running is the goal and you may do a bunch of stuff ranging from more general strength work to more specific running technique stuff.

Something as basic as load tolerance is probably reasonably specific to the movement and the WAY it is being performed, think spinal flexion and back pain, and this might be very important to someone who struggles to pick up their kids or put on their socks, which could actually be their goals and signify recovery far more than just having no pain. We could take a graded approach to building tolerance and confidence or instead look to avoid bending, both could reduce pain but only a former approach might reduce disability, restore function and reduce fear. Advice to avoid things like bending and twisting could be unfounded with populations who do lots of bending and twisting of the lumbar spine not showing a greater prevalence of degeneration in their lumbar spines HERE.

All of these variables might relate to and be slightly different for specific physical aspects of rehab with relation to individually identified goals.

• Loads
• Positions
• Speeds/force
• Environment
• Time
• Objects

Psychosocial perspective

We also have to remember the physical stuff is only part of the process, if exercises do not GET DONE in the first place it becomes a redundant element, however evidence based. As we don’t know quite HOW exactly treatment works for many people and a fair proportion may still not be specific to the physical bit any way, some time spent finding out and then relating your exercise program to specific goals, in action OR explanation, is probably a worthwhile endeavour. This recent paper found that goal setting was an effective way to increase adherence to exercise programs HERE but with the caveat that more data is required. This paper HERE also showed an increased adherence with goal setting.

If we view this from a psychosocial perspective; someone may feel better or more inclined to do something that ACTUALLY relates to his or her individual goals. Personalising treatment, through patient centred care, has been shown to be a feature of therapist and patient interactions that enhance treatment outcomes HERE & HERE. Goals often also indicate people’s preferences and taking patient preferences into account has also been shown to positively affect outcomes.

With one of the key prognostic factors to recover being someone’s PREDICTED EXPECTATION of recovery HERE, anything that relates to improving expectation is likely to all also improve treatment outcomes. I would argue clearly defining individual treatment goals and creating a mutually agreed road map to recovery would positively influence the outcome. This might also influence both self-efficacy, through the planning to achieve the goal, and creating an internal locus of control, two things that are more than likely vital for successfully achieving a rehab program. This paper HERE found goal setting linked to both self efficacy and performance.

A simple clear explanation of why you are doing what you are doing and how it will help their goals will probably improve someone’s perception of your rehab choices even if the intervention is quite general in nature.

Question time

Firstly we need to find out WHAT their goals might be and we might ask question such as:

• What specifically do you feel your problem stops you from doing that you really enjoy?

• Is there anything in your normal everyday life that pain stops you from doing? How does that make you feel?

• Are there activities that you specifically avoid?

• What WOULD you do if pain was not an issue?

Tools such as the patient specific functional scale HERE can be good ways to more formally identify AND quantify goals.

BE SMART

After a goal has been identified, the use of a SMART approach to goal setting may also help to refine the goal then monitor the process of achieving it.

SPECIFIC

Keep it narrow and clearly defined. Goals that are too broad will be hard to measure and achieve.

MEASURABLE

How do you know you have got there? This could be by using a scale such as a VAS or a simple binary yes or no for whether you have achieved the goal set out.

ACHIEVABLE

Goals should be smaller rather than larger or can be broken up into a larger overall goal and smaller goals that can be achieved over shorter term.

So the small goals may change over time whilst a larger goal maybe the summation of many smaller goals.

Activation of the dopamine reward system as small goals are achieved may create a ‘feel good’ factor that keeps people motivated.

REALISTIC

Goals could be unrealistic and therefore unachievable. The people who tend to get the best results from therapy have realistic goals. These can be managed and negotiated between therapist and patient HERE.