Introduction

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According to Lexell & Brogardh, (2014) the rehabilitation process comprises of four steps:

1. Assessment
2. Goal Setting
3. Interventions
4. Outcome Measurement.

Assessment has been discussed in a different article. This article will focus on the second step, goal setting, in the neurorehabilitation process.

Goal setting is used as a tool to improve the quality of the rehabilitation process (Schut & Stam, 1994). A rehabilitation goal is a desired future state to be achieved by a person with a disability as a result of rehabilitation activities. (Mark & Levack, 2018). These goals are actively selected, intentionally created, have purpose and are shared in cases where possible.

According to (Mark & Levack, 2018) once set, rehabilitation goals ought not be left forgotten in a patient’s clinical notes but used in some way to guide clinical decision making, to encourage patients in their efforts, or to help patients, family members and health professionals reflect on process or progress.

Benefits of goal setting.

• Creates common objectives which are essential in teamwork.
• Goal setting has a communication impact, it gives the environment for proper communication between the rehabilitation team and also with the patient and the family.
• Goal setting has a motivational aspect. Proceeding towards or reaching a goal may give the patient, the individual team member and the team as a whole, the satisfaction needed to get and stay motivated.
• Goal setting is important in the assessment of the rehabilitation outcome.

Writing Person-Centered Goals

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Goals are only effective if they are considered desirable by the subject (Wade, 2009).

Setting goals involves two key activities:

1. Goal Selection
2. Goal Documentation

Goal selection

When using the person-centered approach to goal setting the goals are meaningful and relevant to the patient. (Melin, Nordin, Feldthusen, & Danielsson, 2019). This means that setting goals is not associated with the traditional measures of pain, range of motion or strength. The goals should be seen more as hopes, aspirations, and dreams rather than dichotomized into realistic and unrealistic goals.

For proper selection of person-centered goals, the patient and the family have to be involved in the process. They should also have information about the prognosis and the expected level of difficulty for specific goals but still should be allowed to set their preferred goals even though they might be challenging or highly ambitious.

The physiotherapist also needs to have information about the context of the persons life outside the health system and before injury or illness.

In differentiating between long term and short-term goals the key concept is identifying short-term steps that need to be achieved to make progress towards some much longer-term, desired outcome.

Goal Statement

(Randall & Mcewen, 2000) have described an approach to writing patient-centered functional goals. It involves writing down the statements in a way that answers these five questions.

• Who?
• Will do what?
• Under what conditions?
• How well?
• By when?

‘Who?’ should almost always be the patient. Mark & Levack, (2018) comments that writing all goal statements with the patient as the subject of the goals helps rehabilitation teams avoid documenting objectives which actually describe tasks for health professionals (or others) to perform rather than outcomes for the patient to achieve.

‘Will do what?’ should describe the function or activity that the patient is aiming to achieve at the end of therapy

‘Under what conditions?’ describes the environment the goal is to be attained.

‘How well?’ provide prompts to specify the quality of performance.

‘By when?’ describes the time/period constraint.

Example: Mr. A, the patient, will walk 500 meters using a walking aid, indoors, on the six-minute walk test within 14 days.

Other methods for goal statement include;

1. SMART approach

Goals are set to in a way that is; specific, measurable, achievable/assignable, realistic/ relevant and timed. (Jh, Eerdt, Botell, & Wade, 2009).

2. MEANING approach

This approach can be divided into three stages: identifying meaningful goals; connecting to concrete target goals; and bridging the intention- implementation gap. McPherson, Kayes, and Kersten (2015)

Goal setting in ever changing clinical conditions.

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Clinical conditions change, patients get better or at other times get worse i.e. in neurodegenerative conditions. This means that one has to adapt his approach to goal setting in the different stages of care.

A good example of this is the example given in (Mark & Levack, 2018) which details goal setting throughout the rehabilitation period for a patient suffering from stroke. Below, I have given a summary.

Acute rehabilitation phase

In the acute phase of illness after a moderate to severe stroke, the thing that patients and families need most is strong, confident, competent health professional leadership. What most patients generally do not need at this point in recovery (immediately after a life-threatening event) is to be asked open-ended questions about their desired outcomes from rehabilitation a year hence.

So, at this phase what should be done about person-centered care? Fiduciary care can be used. Mark & Levack (2018) describe fiduciary care as involving the health professionals taking charge of decision making over a patient’s health, well-being and treatment during this time of adjustment.  Further they explain that during this period the major goal that should be aimed at should be independent mobility. If the patient’s prognosis doesn’t look too promising this information should be explained to the patient but still while maintaining the optimism.

Post-acute Inpatient Rehabilitation

Post-acute inpatient rehabilitation can be said to start once a person is medically stable and beginning to work towards returning to the community.

This ‘goal’ is usually about a series of achievable, time-bound targets related to a minimum level of functional performance required for community living: walking, talking, eating, toileting, self-cares, arm/hand function and so on. Goals for inpatient rehabilitation can (and should) be individualized to better match the life context and personal values of each person with stroke, but overall, the goals of inpatient rehabilitation will necessarily draw on similar activities required for community living.

The post-acute stage of rehabilitation is the time when health professionals need to begin relinquishing some control over decision making. At some point it might become increasingly clear that a patient is not going to achieve his or her best possible desired outcome. When this happens, revision of goals is likely to be necessary. A goal for some form of walking with aid might need to be replaced by a goal to achieve mobility by use of transfers and a wheelchair.

In this context, opportunities for patients to discuss their disappointment with their recovery ought to be provided and acknowledged. However, patients in this situation also ought to be encouraged to find ways to engage with previously meaningful social roles and occupational pursuits in a modified capacity.

Post-Acute Community-Based Rehabilitation

The period shortly after discharge from hospital is one full of new challenges for people with stroke. Goal setting at this stage helps provide a road map for learning to live with stroke in the community. In early community-based rehabilitation, goal setting should move from a focus on basic functional needs for community living towards being more about personally meaningful occupations and social participation. It is also important to consider goals around holistic well-being.

Thus, in community-based rehabilitation, patients should be encouraged to take much more control over the selection of goals and the direction of therapy, with support from their family where needed.

Long-Term Recovery Following Stroke

Rehabilitation goal setting at this stage should be entirely directed by the person with the stroke and/or his family or caregivers, both in terms of goal selection and development of activities for goal pursuit.

References

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Jh, T., Eerdt, B., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clinical Rehabilitation, 362–361. https://doi.org/10.1177/0269215508101741

Lexell, J., & Brogardh, C. (2014). The use of ICF in the neurorehabilitation process The use of ICF in the neurorehabilitation process. (DECEMBER). https://doi.org/10.3233/NRE-141184

Mark, W., & Levack, M. (2018). Goal Setting in Rehabilitation. In Physical Management for Neurological Conditions (p. 595).

McPherson, K. M., Kayes, N. M., & Kersten, P. (2014). MEANING as a smarter approach to goals in rehabilitation. Rehabilitation goal setting: Theory, practice and evidence, 105-19.

Melin, J., Nordin, Å., Feldthusen, C., & Danielsson, L. (2019). Goal-setting in physiotherapy : exploring a person- centered perspective. Physiotherapy Theory and Practice, 0(0), 1–18. https://doi.org/10.1080/09593985.2019.1655822

Randall, K. E., & Mcewen, I. R. (2000). Writing Patient-Centered Functional Goals. 80(12), 1197–1203.

Schut, H. A., & Stam, H. J. (1994). Goals in rehabilitation teamwork. 16(4), 223–226.

Wade, D. (2009). Goal setting in rehabilitation: an overview of what, why and how. Clinical Rehabilitation, 291–295.