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Three Part Question

In [adults with neurological conditions] does [the Goal Attainment Scale] measure [functional change]?

Clinical Scenario

You are a member of a multi disciplinary team (MDT) working on an adult in-patient neurological rehabilitation unit. A patient is admitted with a neurological condition for a period of rehabilitation. The MDT wants to set goals to direct the patient’s intervention. You want to use an outcome measure that will reflect change in functional ability and/or quality of life.

Search Strategy

Medline 1950-04/11, CINAL 1944-04/11, AMED 1985-04/11, PSYCH INFO 1806-04.11 searched seperately via the OVID interface on ATHENS.
[exp Nervous System Disorders] AND [goal attainment scale*] LIMIT to English.

Search Outcome

198 papers were retrieved in total. 99 remained after deleting the duplicates. After reading the abstracts 2 papers were considered relevant to the question. When downloading the relevant papers two further papers were found by searching the related articles. The final four papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ertzgaard et al, 2011 Sweden	36 articles on GAS related to acquired brain injury (ABI)	Literature review	GAS	It measures a clinically meaningful change in activity/participation status in patients undergoing rehabilitation for disability caused by ABI; providing a more sensitive measure of specific changes than global measurement tools. It allows statistical comparison of outcomes whilst retaining individualised treatment goals. Goals must be both achievable and of interest to the patient. It does not replace standardised ABI assessment tools.	No methodology of literature search; lack of critique - only extracted clinically pertinent information; use of goals from own clinical experience therefore potential bias
Turner-Stokes, 2009, United Kingdom	(N= 164) patients admitted for in-patient rehabilitation following acquired brain injury.	A prospective cohort analysis. Three outcome measures were assessed on admission and discharge, the goal attainment scale (GAS), the Functional Assessment Measure (UK FIM+FAM) and the Barthel Index (BA).	GAS	There was a statistically significant change from baseline and discharge. The median GAS T-Scores moderately correlated with changes in FIM+FAM. Of the 667 goals set by the GAS 74% were achieved, although only 64% of these goals were reflected by changes in the FIM+FAM.	Single-centre study limits the generalizability of the findings. The mapping of goals onto the FIM+FAM was undertaken retrospectively. Some GAS goals crossed a number of areas in the FIM+FAM. No control group.
			UK FIM+FAM	There was a statistically significant change from baseline and discharge
			Barthel Index	There was a statistically significant change from baseline and discharge
Khan et al. 2008 Australia	n=24 people with a diagnosis of multiple sclerosis admitted for comprehensive inpatient rehabilitation.	Prospective observational cohort study.	GAS	Statistically significant difference from admission to discharge, scores are strongly correlated with the Clinical Global Impression scale which differed significantly with the responders and non responders group. GAS was consistently more responsive than either the FIM or Barthel index	Small sample size; Small timescale; Potential for bias as assessed and treated by the same team. Single centre study.
			UK FIM	Statistically significant difference from admission to discharge
			Barthel Index	Statistically significant difference from admission to discharge
Reid and Chesson, 1998 United Kingdom	5 patients (3 women and 2 men) admitted for inpatient rehab within 8 weeks of onset of an acute stroke	Exploratory pilot study	GAS	Patients’ goals were broad and long term whereas therapists’ goals were specific and short term. Due to the possibility of patients’ unrealistic expectations and therapist bias, it is suggested that a supportive framework may be beneficial when joint goal setting.	low level evidence pilot study and small sample size therefore no data analysis, single centre, the assessor was not blinded to the study

Comment(s)

There is a dearth of evidence available which is generally of a poor quality due to potential for bias, small sample sizes and the single-centred study design. It is interesting to note the choice of having 5 or 6 point scales dependent upon the nature of the rehabilitation setting (clinical practice or research). Each approach has associated advantages and disadvantages that would need to be considered. The Goal Attainment Scale displays evidence of being consistently more responsive, and captures more gains beyond those of traditionally used outcome measures such as the UK FIM+FAM and the Barthel Index, which is substantiated in the above texts. It also promotes collaborative goal setting between the patient and therapist.

Clinical Bottom Line

The Goal Attainment Scale is a suitable outcome measure of functional change in adults with neurological conditions; however it is recommended that it be supported by established standardised assessment tools.

References

1. Ertzgaard P, Ward A, Wissel J, Borg J. Pratical considerations for goal attainment scaling during rehabilitation following acquired brain injury. Journal of Rehabilitation Medicine. 2011, 43; 8-14.
2. Turner-Stokes L, Williams H, Johnson J. Goal Attainment Scaling: Does it provide added value as a person-centred measure for evaluation of outcome in neurorehabilitation following acquired brain injury? Journal of Rehabilitation Medicine 2009; 41: 528-535.
3. Khan F, Pallant J, Turner-Stokes L. Use of Goal Attainment Scaling in Inpateint Rehabilitation for Persons With Multiple Sclerosis Archive of Physical Medicine and Rehabilitation 2008, 89 652-659.
4. Reid A and Chesson R. Goal Attainment Scaling: Is it appropriate for stroke patients and their Physiotherapists Physiotherapy 1998; 84 (3): 136-144.