Using Goal Attainment Scaling in physiotherapeutic home-based stroke rehabilitation

Development of a menu of recovery goals to facilitate goal setting after critical illness

OBJECTIVE

To develop an expert-informed (including end users) recovery goal menu for adults recovering from critical illness applicable to the community/home setting.

RESEARCH METHODOLOGY/DESIGN

Stage 1 Item generation: iterative development of domains, sub-domains, and goals in consultation with former intensive care patients, family members and expert clinicians. Stage 2 Content validity assessment: cognitive interviews and the content validity index.

SETTING

Virtual consultation meetings facilitated by the research team at King's College London and Guy's and St Thomas' NHS Foundation Trust.

MAIN OUTCOME MEASURES

Content validity as assessed by: the Item-Content Validity Index (I-CVI), Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score, the Scale Level-Content Validity Index/Average (S-CVI/Ave) score and Average Content Validity Ratio (CVR).

RESULTS

Item generation resulted in a goal menu comprising 4 domains, 22 sub-domains and 95 goals assigned as follows: Self-care: 9 sub-domains with 37 goals, Productivity: 7 sub-domains with 13 goals, Leisure: 3 sub-domains with 25 goals, and Person domain 3 sub-domains with 20 goals. Cognitive interviews resulted in addition of 79 goals and modification of 7, addition of 4 new sub-domains and modification of 4, thus resulting in 4 domains, 26 sub-domains with a total of 174 goals. Twenty-four sub-domains (169 goals) were deemed relevant with Item-Content Validity Index (I-CVI) scores ranging from 0.72 to 1. Two sub-domains (5 goals) did not meet the 0.7 cut-off and were removed. The Scale Level-Content Validity Index/Universal Agreement (S-CVI/UA) score was 0.46; the Scale Level-Content Validity Index/Average (S-CVI/Ave) 0.91. Average Content Validity Ratio (CVR) was 0.93.

CONCLUSION

An expert informed recovery goal menu for former intensive care patients has been developed with excellent content validity. The final goal menu comprises 169 goals within 24 sub-domains grouped under 4 domains.

IMPLICATIONS FOR CLINICAL PRACTICE

This menu will help patients to set goals and increase our understanding of how individuals recover from critical illness.

Patient-centeredness in Physiotherapy - A literature mapping review

Background and purpose: Research on patient-centeredness within physiotherapy points to a need for clarification about what the concept entails in science and practice and how research positions itself within health care. Thus, the aim is to systematically map the characteristics of research on patient-centeredness in physiotherapy and critically discuss the dominant understandings within. Methods: A systematic research mapping was carried out, based on searches in leading bibliographic databases. Four categories were selected in order to characterize the research field: focus, design, theoretical approach and inherent logic. Findings: Of 5,324 studies, 101 were included in the final mapping, pointing to a limited amount of research. The papers included were published in 47 different journals. Two major research foci emerges: one testing or developing technologies (tools) to promote patient-centeredness and one exploring patients' or professionals' experiences related to physiotherapy practice. Most papers reported on empirical research and there seems to be a dearth of conceptual papers. The theoretical approaches applied were mainly psychological, pedagogical and biomedical. The papers included were divided into equal amounts of studies carried out within inherent logics of causality and complexity. Conclusion: The mapping suggests an incipient awareness of patient-centeredness within the research field of physiotherapy. Empirical studies dominate the field, whereas conceptual and critical papers seem in need of wider acknowledgment. The research field is divided into two mutually disconnected trends: one concerned with understanding the complexity of clinical practice and patients' experiences of treatment and illness, and another trend concerned with solving "the problem" of patient involvement.

Development of a symptom menu to facilitate Goal Attainment Scaling in adults with Down syndrome-associated Alzheimer's disease: a qualitative study to identify meaningful symptoms

Background

As life expectancy of people with Down syndrome (DS) increases, so does the risk of Alzheimer’s disease (AD). Identifying symptoms and tracking disease progression is especially challenging whenever levels of function vary before the onset of dementia. Goal Attainment Scaling (GAS), an individualized patient-reported outcome, can aid in monitoring disease progression and treatment effectiveness in adults with DS. Here, with clinical input, a validated dementia symptom menu was revised to facilitate GAS in adults living with Down Syndrome-associated Alzheimer’s disease (DS-AD).

Methods

Four clinicians with expertise in DS-AD and ten caregivers of adults living with DS-AD participated in semi-structured interviews to review the menu. Each participant reviewed 9–15 goal areas to assess their clarity and comprehensiveness. Responses were systematically and independently coded by two researchers as ‘clear’, ‘modify’, ‘remove’ or ‘new’. Caregivers were encouraged to suggest additional items and recommend changes to clarify items.

Results

Median caregiver age was 65 years (range 54–77). Most were female (9/10) with ≥15 years of education (10/10). Adults with DS-AD had a median age of 58 years (range 52–61) and either a formal diagnosis (6/10) or clinical suspicion (4/10) of dementia. The initial symptom menu consisted of 67 symptoms each with 2–12 descriptors (589 total). The clinicians’ adaptation yielded 58 symptoms each with 4–17 descriptors (580 total). Of these 580 descriptors, caregivers identified 37 (6%) as unclear; these were reworded, and one goal area (4 descriptors) was removed. A further 47 descriptors and one goal area were added to include caregiver-identified concepts. The final menu contained 58 goal areas, each with 7–17 descriptors (623 total).

Conclusions

A comprehensive symptom menu for adults living with DS-AD was developed to facilitate GAS. Incorporating expert clinician opinion and input from caregivers of adults with DS-AD identified meaningful items that incorporate patient/caregiver perspectives.

A Simple Goal Elicitation Tool Improves Shared Decision Making in Outpatient Orthopedic Surgery: A Randomized Controlled Trial

Introduction. Shared decision making involves educating the patient, eliciting their goals, and collaborating on a decision for treatment. Goal elicitation is challenging for physicians as previous research has shown that patients do not bring up their goals on their own. Failure to properly elicit patient goals leads to increased patient misconceptions and decisional conflict. We performed a randomized controlled trial to test the efficacy of a simple goal elicitation tool in improving patient involvement in decision making. Methods. We conducted a randomized, single-blind study of new patients presenting to a single, outpatient surgical center. Prior to their consultation, the intervention group received a demographics questionnaire and a goal elicitation worksheet. The control group received a demographics questionnaire only. After the consultation, both groups were asked to complete the Perceived Involvement in Care Scale (PICS) survey. We compared the mean PICS scores for the intervention and control groups using a nonparametric Mann-Whitney Wilcoxon test. Secondary analysis included a qualitative content analysis of the patient goals. Results. Our final cohort consisted of 96 patients (46 intervention, 50 control). Both groups were similar in terms of demographic composition. The intervention group had a significantly higher mean (SD) PICS score compared to the control group (9.04 [2.15] v. 7.54 [2.27], P < 0.01). Thirty-nine percent of patient goals were focused on receiving a diagnosis or treatment, while 21% of patients wanted to receive education regarding their illness or their treatment options. Discussion. A single-step goal elicitation tool was effective in improving patient-perceived involvement in their care. This tool can be efficiently implemented in both academic and nonacademic settings.

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.

Reliability of the Client-Centeredness of Goal Setting (C–COGS) Scale in Acquired Brain Injury Rehabilitation

OBJECTIVE. To examine the internal reliability and test–retest reliability of the Client-Centeredness of Goal Setting (C–COGS) scale.

METHOD. The C–COGS scale was administered to 42 participants with acquired brain injury after completion of multidisciplinary goal planning. Internal reliability of scale items was examined using item–partial total correlations and Cronbach’s α coefficient. The scale was readministered within a 1-mo period to a subsample of 12 participants to examine test–retest reliability by calculating exact and close percentage agreement for each item.

RESULTS. After examination of item–partial total correlations, test items were revised. The revised items demonstrated stronger internal consistency than the original items. Preliminary evaluation of test–retest reliability was fair, with an average exact percent agreement across all test items of 67%.

CONCLUSION. Findings support the preliminary reliability of the C–COGS scale as a tool to evaluate and promote client-centered goal planning in brain injury rehabilitation.

Old tool, new tricks? A new adaptation of the Modified Falls Efficacy Scale

Aim:

Measuring outcomes is important in community rehabilitation programs (CRPs), both at the individual and service level. Identifying global outcome measures that can be used for all patients is challenging given the diversity of this client group.

Method:

This observational study explored measurement properties of the Modified Efficacy Scale (MES), which is an adaptation of the Modified Falls Efficacy Scale. The MES was used to assess patient confidence in performing activities without reference to falls and was trialled with 221 CRP patients. Floor and ceiling effects, responsiveness to change and minimal clinically important difference (MCID) scores were measured and compared with scores for the same sample of patients using the Lawton Instrumental Activities of Daily Living (IADL) scale.

Results:

The MES showed evidence of convergent validity and was responsive to change. Both scales showed ceiling effects on discharge, although this was more pronounced with the Lawton IADL scale (40%) than the MES (21%). Both scales had small values for MCID relative to scale width.

Conclusions:

The MES demonstrated evidence of validity and has a less pronounced ceiling effect compared with the Lawton IADL scale. The implications of a ceiling effect should be considered in the context of the assessment purpose.

The use of patient-specific measurement instruments in the process of goal-setting: a systematic review of available instruments and their feasibility

OBJECTIVE

The aim of this study was to identify the currently available patient-specific measurement instruments used in the process of goal-setting and to assess their feasibility.

METHODS

After a systematic search in PubMed, EMBASE, CINAHL, PsychINFO and REHABDATA, patient-specific instruments were included, structured in a goal-setting practice framework and subjected to a qualitative thematic analysis of feasibility.

RESULTS

A total of 25 patient-specific instruments were identified and 11 were included. These instruments can be used for goal negotiation, goal-setting and evaluation. Each instrument has its own strengths and weaknesses during the different phases of the goal-setting process. Objective feasibility data were revealed for all instruments such as administration time, instruction, training and availability. Subjective feasibility could only be analysed for the Canadian Occupational Performance Measure, Goal Attainment Scaling, Self-Identified Goal Assessment and Talking Mats. Relevant themes were that Canadian Occupational Performance Measure and Goal Attainment Scaling were time consuming and difficult for patients with cognitive problems, but they facilitated goal-setting in a client-centred approach. Talking Mats was especially feasible for patients with cognitive and communication impairments.

CONCLUSIONS

A total of 11 instruments were identified, and although some had strong points, there is no single good instrument that can be recommended specifically. Applying a combination of the strengths of the available instruments within a goal-setting framework can improve goal setting and tailor it to individual patients.