When patients set the goals of therapy…

If you’ve been following my blog over the past week or so, you’ll see I’ve been discussion goal setting as part of pain management rehabilitation.  I’ve looked at the things patients may ask for, and the difference between these goals and the goals that clinicians may need to set directly related to the treatment aims. I’ve also looked at the place of goals in life generally, the subskills used to develop and achieve goals, and what happens to people when they can’t achieve the goals they set. I’ve also looked at using Goal Attainment Scaling as a form of outcome measurement. Today I want to look at a study where the effect of patients being involved in goal-setting was measured. Unfortunately, it’s not a study within the chronic pain setting, instead it’s about goal-setting within an inpatient neurological rehabilitation unit. There are clear differences between the model this unit uses compared with most chronic pain management settings – but there are also things we can learn, so here goes!

This study was carried out in The Neurological Rehabilitation Unit at the National Hospital for Neurology and Neurosurgery, London, UK, and involved 200 in-patients, half of whom were involved in ‘normal practice’ and the other half were involved in a programme where increased participation in goal-setting was encouraged.  The patients had a range of neurological conditions including stroke, multiple sclerosis, spinal cord lesions, and a variety of other less common conditions like peripheral nerve disease and central nervous system tumours.

This Unit has a care pathway, which is a set of interlinked goals relating to five main dimensions:

(1) health maintenance,

(2) cognitive functioning,

(3) personal activities of daily living,

(4) participation and

(5) communication.


All admissions to the unit over an 18 month period were included in the study, except if they had limited ability to communicate in English.  This meant that a total of five patients were excluded.    A ‘repetitive block design’ was used to determine the treatment protocol used, with each block lasting 3 months.

‘At the onset of each phase all staff (physiotherapists, occupational therapists, speech and language therapists, nurses and doctors) working on the neurological rehabilitation unit attended a training session on either the ‘‘usual practice’’ (phase A) or the ‘‘increased participation’’ (phase B) approach which was to be used.’


Four measures were used: Patients’ beliefs about their involvement rated on a four point scale; Goal relevance was measured as a global rating using a 10 cm visual analogue scale, with the anchors being ‘not at all relevant’ and ‘highly relevant’; each goal was rated on a five point scale from (1) highly relevant to (5) of not relevance whatsoever; patients overall satisfaction was rated on a 10 cm visual analogue scale; the distribution of the goal components was recorded on the five care pathway dimensions , as were the outcome or end status of the goals, and reasons for non-completion of goals (variances) were collected for comparative purposes.  Three functional outcome measures were also taken on admission and discharge (unfortunately, not long-term outcomes) – Functional Independence Measure (FIM),  London Handicap Scale, and  General Health Questionnaire (GHQ-28).

The flowchart shows you the two pathways patients may follow, depending on the month they are admitted.


In the experimental group, patients are asked to complete a structured goal-setting workbook before admission, and attend clinical goal-setting meetings.  In the ‘treatment as usual’, goals are set by therapists without direct input from patients.


There were no significant differences between the two groups, except mean age for the ‘‘increased participation’’ group was 4 years younger than ‘treatment as usual’.

Patients correctly identified the origin of goals, depending on the group they were in, and they also identified that their goals were both more relevant, and that they were more satisfied if they were in the experimental group.

Different types of goals were set when participants increased their input to goal-setting.  Notably, people in the experimental group identified a greater number of ‘participation’ goals compared with the ‘treatment as usual’ group.  There were fewer overall goals set in the experimental group, but there was no difference between the number of goals achieved in each group.  Finally, there were no differences in the functional outcome measures between the groups at discharge.

So, what does this mean?

Well, one aspect that did differ between the groups was the degree of satisfaction with treatment – in pain management at least, there is some evidence that expectations that are well-met during treatment are associated with slightly better outcomes. It probably also meant (although this wasn’t directly studied), that adherence to treatment activities during treatment was probably a little higher.  Happier patients probably means happier staff!

It’s interesting that there was no data on the long-term adherence to treatment activities, nor on outcomes between the groups.  I’m inclined to think that people who believe their goals are more relevant to their real life would be more likely to carry on with the treatment activities and therefore the outcomes over time might be more durable.

The main difficulty with generalising from this example to other settings is about the methodology.  This isn’t a blinded RCT.  It would be really difficult to set up a full-blown RCT, but it is a limitation.  There could be systematic differences between the two groups that weren’t readily identifiable – or perhaps there were differences in the way the staff facilitated the processes.

Another difficulty is that this was an in-patient setting, while most pain management in New Zealand, anyway, is within an outpatient setting.  I’m not sure how much this would influence the processes, apart from probably a much closer team working environment in an in-patient setting compared with outpatient.

Patients experiencing chronic pain often report that they feel they are not listened to, and that their concerns are not addressed.  Perhaps by following a systematic process of setting goals, similar to this study, this concern could be addressed.

On the other hand, ACC asks for claimants to determine their ‘functional goals ‘.  As I mentioned when I first posted about goal-setting, lots of patients simply want their pain to be gone, and life to return to normal. It’s not easy to elicit clear goals from patients as many haven’t set goals routinely, and given the lack of direction and sense of disillusionment that many face as part of having chronic pain, perhaps we need to use a structured process to help people establish goal areas, then work through how they might achieve the goals – during both therapy and afterward.

This isn’t the last post from me on goal-setting.  I’m on the hunt to find some good material on which to base a process for developing good goal setting strategies.

What strikes me, though, is the real lack of good clinically-based research demonstrating the effect of goal-setting on patients, and to work out what works, and what doesn’t.  Even some nice descriptive studies would be worthwhile to explore the experiences of patients as they participate in goal-setting!  This is a challenge, folks!  Let’s do it!

R. C Holliday, S. Cano, J. A Freeman, E D. Playford (2007). Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit Journal of Neurology, Neurosurgery & Psychiatry, 78 (6), 576-580 DOI: 10.1136/jnnp.2006.102509

A (brief) rant! A list of middle-aged grumbles

Here are some pet hates – I was going to post this on Friday, but given that my post on assessments is still a work in progress, here it is.

1. Why do some people have to wait right until the end of the consultation to tell you that they REALLY wanted to see you about…and it’s something really important?
2. Why do quality systems in healthcare focus on process rather than outcome? You can tick all the boxes but STILL be doing nothing for the patient!
3. Why is ‘patient-centred’ really ‘patient-driven’? Don’t we as health professionals have to recommend what is good science rather than ‘what the patient wants?’
4. Why do health care facilities put so little emphasis on clinically-driven research? Why is there no specific time/money set aside for clinically-based research carried out by clinicians?
5. Why do some doctors continue to tell people with chronic pain that there is ‘something else that we can try’ when the person is really ready to move on with life? And that ‘something else’ is a techno-fix with limited evidence-base?
6. Why do clinicians keep saying ‘but if we could only treat with what we have evidence for we wouldn’t be able to do anything’?
7. Why do patients decide not to use prescribed medication because it’s ‘not natural’ but think nothing of ingesting nonregulated ‘health supplements’ that could be made of anything? Especially marijuana?!
8. Why do people decide to come to pain management – then not actually DO anything that’s recommended – then tell you ‘it doesn’t work’?
9. Why do meetings take up so much time for ‘information-giving’ when an email could send the information out more efficiently and a meeting could then be used to discuss the implications?
10. Why do office systems in a health care system work for the administrators BUT not work for clinicians?
11. The word ‘suffer’ when used in conjunction with chronic pain – experiencing pain may be compulsory, but suffering is optional.
12. People who believe in ‘alternative’ health care but can’t or won’t put up evidence to support it, yet argue about the need to be ‘inclusive’, and are convinced that conventional health care is corrupt. Especially hospital or academic institutions who are supposedly committed to evidence-based (science-based) processes.

Oh and a final gripe – why is it that four years after something has been suggested, some ‘new’ comes in, says exactly the same thing and it’s suddenly groovy and amazing and the next thing since sliced bread? And why is it that even when it’s groovy and amazing – it STILL takes another 4 years to actually be put in place?

Oooh! I lied – there’s more!
Why is it that some therapists just HAVE to tell you that another professional group is ‘trying to take over our role’, when there’s no evidence that one profession can ‘do it better than’ another?!

I must stop this, I’m on a roll… Can YOU add to it?! Please do!
Must be mid-winter ‘cos this list is soooo incomplete! Bring on Spring I say!
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