Goal setting, using goal attainment scaling, as a method to identify patient selected items for measuring arm function

Goal-Setting in Multiple Sclerosis-Related Spasticity Treated with Botulinum Toxin: The GASEPTOX Study

Spasticity is one of the most disabling symptoms in multiple sclerosis (MS). Botulinum toxin injection (BTI) is a first-line treatment for focal spasticity. There is a lack of evidence of a functional improvement following BTI in MS-related spasticity. To describe goal-setting for BTI in MS, and evaluate the degree of attainment, using goal attainment scaling (GAS) 4-to-6 weeks after injection session, a one-year multi-center retrospective observational study assessing goal-setting and achievement during BTI session in spastic patients with MS was set up. Following the GAS method, patients and their physicians set up to three goals and scored their achievement 4 to 6 weeks thereafter. Commonly used goals from three centers were combined into a standardized list and 125 single BTI sessions were analyzed. The most frequent goals regarded lower limb (LL) impairments (equinovarus foot, toe claw) or locomotion (stability, walking distance, clinging) and accounted for 89.1%, versus 10.9% for upper limb (UL), mostly for mild-to-moderate MS. Overall, goals were frequently achieved (85.77%) mainly when related to gait and mobility rather than hygiene and ease of care. This study gives an overview on the most frequent, relevant, and achievable goals to be set in real-life practice of BTI for spasticity management in MS.

Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs

BACKGROUND

Assess the feasibility of using goal attainment scaling (GAS) in care planning for older adults with complex needs. GAS is an individualized approach to goal setting and follow up using a quantified scale. To date, little is known about the feasibility of GAS among this population.

METHODS

We conducted a qualitative study with a sample of 28 older adults and 23 providers from diverse settings to evaluate the value and challenges of this approach. We conducted semi-structured interviews and iteratively coded and analyzed interview transcripts for themes related to value, challenges, and implementation.

RESULTS

Most older adults and providers reported that the GAS approach added value to the care encounter. GAS supported collaboration and patient accountability for their goals, though it could be demotivating to some patients. Some older adults and providers noted that GAS could be confusing and that it was uncomfortable to talk about negative outcomes (i.e., the - 2 and - 1 boxes of the scale). Factors that facilitated implementation included using visual copies of the GAS forms, having an established patient-provider relationship, practicing the approach, and having previous goal-related clinical training.

CONCLUSIONS

GAS was feasible to implement across diverse settings, and, despite challenges, both older adults and providers reported that it added value to care planning encounters with the potential to improve delivery of person-centered care. Further efforts to demonstrate the applicability and benefit of this method for older adults are warranted, particularly to address implementation of the approach.

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

[Impact of integrated upper limb spasticity management including repeat botulinum toxin type A (BoNT-A) injections on patient-centred goal attainment in real-life practice: results from the prospective, observational Upper Limb International Spasticity cohort study (ULIS-III) in a Russian subpopulation]

OBJECTIVE

To assess the longitudinal attainment of patient-centred and function related goals after integrated spasticity management including repeated cycles of botulinum toxin A type A (BoNT-A) injections in real life settings over a period of 2 years. The article presents analysis of the results within the subpopulation of patients from Russia.

MATERIAL AND METHODS

This international, multicentre, observational, prospective, longitudinal cohort study (registered at clinicaltrials.gov as NCT02454803) included patients ≥18 years old with upper-limb spasticity of any aetiology in whom a decision had already been made to inject any BoNT-A formulation commercially available in the Russi. The treatment outcomes were evaluated using the Upper Limb Spasticity Index, which combines the patient-centred Goal Attainment Scaling (GAS) with a set of targeted standardised measures to assess the neurological impairment. The extent of functional impairment was assessed using the DAS.

RESULTS

168 Russian patients from 7 sites with a mean age of 49.8 years participated in the study. The Russian subpopulation had some differences from the overall study population in baseline characteristics of patients and injection practices of BoNT-A treatment. During the study period, the majority of Russian patients received AboBoNT-A (Dysport) injections - 142 (85%) patients at cycle 1, while OnaBoNT-A (Botox) was used in 14 (8%) patients, and IncoBoNT-A (Xeomin) - in 12 (7%) patients. Higher doses of AboBoNT-A were observed compared to the overall population, mean doses of AboBoNT-A between cycles 1 and 4 were 909-934 U in the Russian patients and 814-859 U in the overall population. In general, patients of the Russian subpopulation successfully achieved their treatment goals. The mean cumulated GAS T-score over the study was 51.1±3.0, marginally exceeding the same parameter in the overall population (49.5±5.9). Across the 6 goal domains, cumulated GAS T-scores in Russian subpopulation were highest for the goals related to passive function and pain relief, with mean scores of 51.8±4.2 and 51.6±4.8, respectively. In the overall population cumulated GAS T-scores were highest for involuntary movements (mean 50.5±5.6) and pain relief (mean 50.4±6.2). The lowest GAS T-scores were for the treatment goals related to active function in both Russian subpopulation and overall population, the mean scores were 48.3±5.5 and 46.6±7.4 respectively. The study results also showed significant improvement in in terms of reduction of muscle tone according to MAS (Modified Ashworth Scale) and the extent of functional impairment according to DAS (Disability Assessment Scale).

CONCLUSIONS

The results of this subgroup analysis on patients from Russia showed high effectiveness of repeated cycles of BoNT-A injections as part of the integrated upper limb spasticity management conducted in real life settings, both in terms of reduction of muscle tone and correction of functional impairment, which contributes to the successful achievement of the treatment goals. The right choice of individual patient-centred treatment goals and methods for assessing their achievement are important components of the treatment and rehabilitation process for patients with spastic paresis of the upper limb.

Psychometric properties of measures of upper limb activity performance in adults with and without spasticity undergoing neurorehabilitation-A systematic review

INTRODUCTION

This systematic review appraises the measurement quality of tools which assess activity and/or participation in adults with upper limb spasticity arising from neurological impairment, including methodological quality of the psychometric studies. Differences in the measurement quality of the tools for adults with a neurological impairment, but without upper limb spasticity, is also presented.

METHODS

29 measurement tools identified in a published review were appraised in this systematic review. For each identified tool, we searched 3 databases (Medline, Embase, CINAHL) to identify psychometric studies completed with neurorehabilitation samples. Methodological quality of instrument evaluations was assessed with use of the Consensus-based Standards for the Selection of Health Status Measurement Instruments (COSMIN) checklist. Synthesis of ratings allowed an overall rating of the psychometric evidence for each measurement tool to be calculated.

RESULTS

149 articles describing the development or evaluation of psychometric properties of 22 activity and/or participation measurement tools were included. Evidence specific to tool use for adults with spasticity was identified within only 15 of the 149 articles and provided evidence for 9 measurement tools only. Overall, COSMIN appraisal highlighted a lack of evidence of measurement quality. Synthesis of ratings demonstrated all measures had psychometric weaknesses or gaps in evidence (particularly for use of tools with adults with spasticity).

CONCLUSIONS

The systematic search, appraisal and synthesis revealed that currently there is insufficient measurement quality evidence to recommend one tool over another. Notwithstanding this conclusion, newer tools specifically designed for use with people with neurological conditions who have upper limb spasticity, have emergent measurement properties that warrant further research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014013190.

Feasibility of six-point Goal Attainment Scale among subacute and chronic stroke patients

Feasibility of six-point Goal Attainment Scale among stroke patients were examined. Thirty-five subacute and chronic stroke patients with upper limb function problems were included (December 2015-March 2017). Sixty-minute conventional therapy and 30-minute occupational therapy was provided on every consecutive weekday, for 4 weeks. Beside Functional Independence Measure, Action Reach Arm test, Fugl-Meyer upper extremity assessment motor function subtest and six-point Goal Attainment Scale were collected. The content of the previous tests was linked with International Classification of Functioning, Disability and Health domains. Feasibility characteristics were checked according to previous feasibility studies and the following aspects: acceptability, demand, implementation, practicality, integration, and expansion. Data analysis was done in 2018. Participants' global functions were described with the Functional Independence Measure median points were 116.5. All of the outcome measures showed significant improvement at group level (P < 0.001). Most of the goals matched to one or more International Classification of Functioning, Disability and Health domains but were not covered with the Action Reach Arm test or the Fugl-Meyer tests. Association between clinically relevant change of the first Goal Attainment Scale and the other tests was not significant. Six-point Goal Attainment Scale proved to be a feasible outcome measure among subacute and chronic stroke participants. It completed the functional picture of a patient, beside standardized measures. Further studies needed to complete the psychometric properties of six-point Goal Attainment Scale among stroke patients and in other patient groups.

Botulinum toxin A injection in the management of shoulder muscle overactivity: A scoping review

The majority of studies examining botulinum toxin A (BTX-A) in the management of upper limb muscle overactivity and pain focus on the distal arm and hand. Research has begun to look at BTX-A efficacy in more proximal upper limb muscles, with literature showing equivocal findings. This scoping review identified 15 studies meeting inclusion criteria whose data were examined against three outcome variables: muscle overactivity, range of movement and pain. Overall, while the majority of injected participants improved on these variables, between-study methodological variability such as research design potentially underpowered studies and arbitrary decision making gave a high likelihood of influencing the interpretation of their results. Future research is warranted, with a robust focus on functional anatomy, a critical appraisal of how BTX-A may help the individual being studied and utilising individualised rather than protocol-driven research paradigms.

Hybrid Rehabilitation Therapies on Upper-Limb Function and Goal Attainment in Chronic Stroke

This study examined the treatment effects between unilateral hybrid therapy (UHT; unilateral robot-assisted therapy [RT] + modified constraint-induced movement therapy) and bilateral hybrid therapy (BHT; bilateral RT + bilateral arm training) compared with RT. Thirty patients with chronic stroke were randomized to UHT, BHT, or RT groups. Preliminary efficacy was assessed using the Fugl-Meyer Assessment (FMA), the Chedoke Arm and Hand Activity Inventory (CAHAI), and the goal attainment scaling (GAS). Possible adverse effects of abnormal muscle tone, pain, and fatigue were recorded. All groups showed large improvements in motor recovery and individual goals. Significant between-group differences were found on GAS favoring the hybrid groups but not on FMA and CAHAI. No adverse effects were reported. Hybrid therapies are safe and applicable interventions for chronic stroke and favorable for improving individual functional goals. Treatment effects on motor recovery and functional activity might be similar among the three groups.

Inter-rater reliability of the Chedoke Arm and Hand Activity Inventory

BACKGROUND

The Chedoke Arm and Hand Activity Inventory (CAHAI) is an assessment of upper limb function designed for use in the stroke population. The CAHAI has strong reliability and validity in this population; however, it is unknown whether this measure can be used with other clinical populations such as acquired brain injury (ABI).

PURPOSE

The purpose of this study was to estimate the inter-rater reliability of the CAHAI when used with persons with ABI.

METHODS

The research design was an observational parameter estimation study. The administration of the CAHAI was videotaped for 6 persons with ABI. To estimate inter-rater reliability each video was assessed independently by 6 clinicians yielding a total of 36 assessments. A Latin square design was used to balance the order raters evaluated the videos. Shrout and Fleiss Type 2,1 intra class correlation coefficients (ICC) and standard error of measurement (SEM) were calculated to estimate inter-rater reliability of the CAHAI.

RESULTS

Inter-rater reliability was high ICC = 0.96 (95% CL: 0.88, 0.99) and the SEM was 3.35 (95% CL: 2.63, 4.63) CAHAI points.

CONCLUSIONS

These results suggest that the CAHAI, although designed for use in the stroke population, can be used reliably in the ABI population.

Development of a measure of therapy provision for spasticity management in the paretic lower limb - the Leg Therapy recording Schedule (LegTS)

PURPOSE

In rehabilitation studies, it is critical to understand the constituents of interventions. First, to enable replication of the work and second, to identify what treatments work best. The development of a tool to describe and quantify therapy interventions in the context of focal spasticity management is presented.

METHODS

Potential intervention categories were identified from: (a) retrospective analysis of prospectively collected data from a cohort of patients (n = 62) receiving physical interventions in the context of botulinum toxin (BoNT) injection for leg spasticity and (b) cognitive de-briefing with Patient and Carer Advisory Group (PCAG) of patient and carer dyads (n = 8). Item reduction was achieved through consultation with a purposively-selected group of physiotherapists and occupational therapists (n = 16) in a two-round Delphi process. This was followed by review of findings by PCAG members.

RESULTS

A list of 24 possible therapy categories were identified and then reduced, resulting in a tool with two domains: (1) postural management; four categories and (2) exercise and retraining; four categories. The Leg Therapy recording Schedule (LegTS) wording and presentation were refined for clinical and research use.

CONCLUSIONS

The LegTS is designed to record therapy interventions for the paretic lower limb in the context of spasticity intervention. Content and face validity have initially been addressed within the development process. Implications for Rehabilitation Clinicians need to understand intervention effectiveness, and to do so, it is critical to capture all the components of a complex intervention. In clinical practice or research, patient experience measures are required to capture the complexity of intervention provided and monitor intervention effectiveness on a case by case basis. Clinicians involved in rehabilitation and management of focal spasticity in the leg can use the Leg Therapy recording Schedule (LegTS) to enable an understanding of the entirety of the intervention package provided.