Goal setting in stroke rehabilitation: review suggests more research needed

Stroke survival rates in the UK are improving, with an increasing number of stroke survivors undergoing post-stroke rehabilitation.

The latest NICE guidelines for long-term rehabilitation after stroke and the UK National Clinical Guidelines for Stroke have both identified goal setting as an integral, effective and efficient process which should play a prominent role in stroke rehabilitation.

Goal setting consists of identifying and agreeing on specific behavioural goals and then working towards achieving these. NICE advises that multidisciplinary goal setting meetings should take place at least once a week.

With such national guidelines advocating goal setting in stroke rehabilitation, it is essential that we review the evidence for its effectiveness and acceptability.

Stroke causes a wider range of disabilities and has a greater disability impact than other chronic diseases (Adamson,  Beswick & Ebrahim, 2004) therefore it is vital that we determine the most effective rehabilitation strategies for stroke survivors specifically.

A recent systematic review by reviewers from Queen Margaret University, the University of Edinburgh and Glasgow Caledonian University did just this; evaluating and discussing the evidence for goal setting specifically in stroke rehabilitation.

Goal setting consists of identifying and agreeing on specific behavioural goals and then working towards achieving these.

Goal setting consists of identifying and agreeing on specific behavioural goals and then working towards achieving these.

Methods

The reviewers conducted an extensive and systematic search including searching 13 databases, Current Controlled Trials and the Stroke Trials Directory. Studies of any methodological type and involving any form of goal setting were included.  Studies were included if they evaluated either the effects or experiences of goal setting.

As this review was focussed on goal setting in stroke survivors specifically, 22 studies were excluded as stroke specific data could not be obtained. A rigorous selection and screening process resulted in 17 studies selected for inclusion in the review, involving 614 stroke survivors, 43 professionals and 38 carers.

Results

Effects of goal setting

  • In two of the studies, the Canadian Occupational Performance Measure (COPM) was used to guide goal setting. The COPM is an instrument used to support goal setting and detect changes in how people perceive their performance and how satisfied they are in certain problem areas or activities.  Both of these studies found significant improvements in performance perception and satisfaction, although they were assessed by the reviewers as having methodological weaknesses.
  • Two further studies found positive effects of goal setting on goal performance, however these were single case studies from which limited conclusions can be drawn.
  • One study found improvements in perceptions of self-care ability, but we cannot be sure whether this translated into improvements in actual self-care.
  • Another study, which used COPM guided goal setting, found that participants were able to recall more treatment goals and manage more tasks than a control group who did not participate in goal setting.  The reviewers warn however, that the two groups had significant differences at the start of the study, therefore results should be interpreted with caution.

Experiences of goal setting

  • Ten studies examined the experiences of a goal setting intervention, with reviewers integrating the various themes that emerged from these studies.
  • Participants often had different perceptions of goal setting than healthcare professionals, with participants more optimistic than health professionals about the goals they expected to achieve.
  • Participants and health care professionals also tended to set different types of goals, with participants setting general longer-term functional goals and health care professionals setting short term specific goals.  This inconsistency sometimes resulted in negative relationships between healthcare professional and patient.
  • Participants were also often unclear about the goal setting process including the meaning of goal setting and the role they played in the process.
  • Studies also identified a number of barriers to effective goal setting including participant cognitive and communication difficulties and increased demands on the health professionals’ time.
  • Nevertheless, professionals viewed goal setting to be a useful tool that allowed them to include the participant in identifying, prioritising and evaluating goals.
Patients were often unclear about their role in this process.

Patients were often unclear about their role in the goal setting process.

Conclusions

The reviewers make a number of conclusions, including suggesting that goal setting may improve some aspects of stroke survivor outcomes such as self-care ability and goal achievement.  Considering the varying methodological quality of the studies, varying methods of goal setting used and various outcome measures used however, they reasonably conclude that:

No firm conclusion could be arrived at regarding the effectiveness of goal setting.

The reviewers also highlighted that there were differences between stroke survivors and health professionals with regards to their goal setting experiences. The two groups tended to have different expectations, goals and thoughts about goal setting.  Stroke survivors were often unclear about the goal setting process. This is not surprising given that the reviewers found stroke survivors were sometimes not involved in the goal setting process; instead goals were set by health professionals without fully consulting the stroke survivor. Resolving these discrepancies and involving the stroke survivor in the goal setting process may result in improved satisfaction and outcomes.

Summary

This systematic review provides us with some useful insights into goal setting in stroke rehabilitation. With goal setting promoted in several national guidelines as essential for improving the outcomes of stroke survivors undergoing rehabilitation, both the lack of gold standard research and perhaps wary attitudes of stroke survivors towards goal setting certainly need to be tackled.  It not this elf’s opinion that goal setting doesn’t result in improvements; rather that further research is necessary to determine which goal setting approaches are most affective and appropriate for the stroke population.

It is also striking that although a number of studies identified communication or cognitive difficulties as a barrier to goal setting, only 2 out of the 17 studies in the review included stroke survivors with such difficulties.  Furthermore in one study 63% of participants were unable to complete the COPM due to communication or cognitive difficulties.  With 1 in 3 stroke survivors experiencing a communication difficulty, it is essential that research does not exclude people with such difficulties and indeed works to determine the most suitable method of including them in goal setting.  Doing so could target some of the barriers faced by health professionals and stroke survivors by determining goal setting practices which are acceptable for people with a range of difficulties and provide the best results within the busy stroke rehabilitation environment.

With guidelines recommending that goal setting is done, it's about time that we found the evidence to support it!

With guidelines recommending that goal setting is done, it’s about time that we found the evidence to support it!

Links

Sugavanam T., Mead G., Bulley C., Donaghy M. & van Wijck F. (2013) The effects and experiences of goal setting in stroke rehabilitation – a systematic review.  Disability and Rehabilitation, 35(3), 177-190. [PubMed abstract]

Clinical guideline 162: Stroke rehabilitation – Long-term rehabilitation after stroke. National Institute for Health and Care Excellence, 2013.

National clinical guideline for stroke, 4th edition (PDF). Royal College of Physicians, 2012.

Adamson, J., Beswick,A. and Ebrahim,S. (2004) Is stroke the most common cause of disability? Journal of Stroke and Cerebrovascular Diseases, 13(4), 171-177.  [PubMed abstract]

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Jennifer Dryden

Jennifer Dryden
Jenny is a PhD student and trainee health psychologist at the University of Strathclyde, conducting research into adjustment to life after stroke. She has a BA in Psychology from the University of Strathclyde and a masters in Health Psychology from the University of Stirling. Her volunteering and work with stroke survivors has greatly influenced her research focus and she has a particular interest in developing interventions that are acceptable and implementable in practice.

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