key: cord-0021301-p2rr39x4
authors: Haladay, Douglas; Swisher, Laura; Hardwick, Dustin
title: Goal attainment scaling for patients with low back pain in rehabilitation: A systematic review
date: 2021-09-22
journal: Health Sci Rep
DOI: 10.1002/hsr2.378
sha: b28ac5cc6ffc4169cce3ef28e39b319ce23f631c
doc_id: 21301
cord_uid: p2rr39x4

BACKGROUND AND AIMS: Goal attainment scaling (GAS) has been widely applied to chronic conditions; however, only recently has it been used for patients with low back pain (LBP). The objectives of this systematic review were to (a) examine the characteristics and rigor of published studies of GAS in the rehabilitation of patients with LBP, (b) describe how GAS has been applied in patients with LBP, and (c) evaluate the responsiveness and validity of GAS as an outcome measure in patients with LBP. METHODS: A systematic search of the CINAHL, PubMed, and MEDLINE databases was performed (1968 and 1 September 2020) in addition to hand searching. Studies including GAS procedures in patients with LBP during rehabilitation were included in the review. Two authors independently selected studies for inclusion and determined levels of evidence using the Oxford Levels of Evidence and rated each study for quality using the Newcastle‐Ottawa scale and reporting transparency using the STROBE statement checklist. RESULTS: Six Level IV and one Level III/IV study were included in this review (search produced 248 studies for review). These studies assessed GAS feasibility, validity, sensitivity, and association with other outcome measures in patients with LBP. Findings suggest that patients with LBP are able to identify and set individualized goals during GAS, while GAS may be more sensitive to change and may measure different aspects of the patient experience as compared with fixed‐item patient‐reported measures. Additionally, GAS may have a therapeutic effect while improving patient outcomes and may be associated with patient satisfaction. CONCLUSION: Based on this review, GAS shows promise as a feasible patient‐centered measure that may be more responsive to change than traditional outcome measures. However, GAS has been inadequately developed and validated for use during rehabilitation in patients with LBP.

Low back pain (LBP) is the second most common cause of disability in the general population, is the most common cause of activity limitation and disability in people under the age of 45 in the United States, and is globally the leading cause of years lived with disability. [1] [2] [3] [4] [5] Direct and indirect costs due to LBP continue to rise and are estimated to approach 626 billion dollars annually in the United States, 6, 7 and estimates from Europe indicate up to 2% of gross domestic product. 8, 9 In 2015, 3.67 million people between 18 and 64 years of age indicated they were unable to work due to chronic back or neck pain, while an additional 1.75 million indicated that their work was limited due to chronic back or neck pain. 10 Physical therapists are commonly involved in the management of patients with LBP [11] [12] [13] ; however, it has been suggested that the use of standardized outcome measures may be time-consuming, confusing, and difficult for patients to complete. 14 The present healthcare environment emphasizes patientcentered outcomes 15 ; however, current measures used for patients with LBP often fail to incorporate patient-centeredness. 16 Patientcentered outcomes address the needs of healthcare providers and researchers for measures to accurately assess the effectiveness of interventions for patients with LBP.

Numerous standardized outcomes exist for healthcare providers to measure changes in patients with LBP, including the use of measures of pain and disability, such as the numerical rating scale and Oswestry disability index. [17] [18] [19] While these measures are typically considered the current standard for research and clinical practice, 18 the isolated use of such measures to guide clinical decision-making and the meaningfulness of these measures to patients remains unclear. 20 These measures provide important information regarding the interpretation of populations in group studies; however, their usefulness in making decisions about individual patients is often limited. 21, 22 Patients with LBP define improvement based on their capacity to reengage in activities and return to participation that is important to them as individuals. 23 Standardized fixed-item patientreported outcome measures alone may not fully reflect the scope of a patient's impairments, activity limitations, and participation restrictions because these measures often disregard the needs of each individual patient. Froud et al suggest that researchers develop outcome measures that address social factors (eg, the impact of LBP on relationships and worry about work). 24 Failure to capture and relate progress to the unique experience of individuals with LBP may explain the low to modest treatment effects reported for most intervention studies for chronic LBP, even when findings are aggregated in systematic reviews. [25] [26] [27] [28] [29] [30] [31] [32] [33] Several researchers have suggested that outcome measures where each patient can identify his/her particular treatment goal(s), such as is done in goal attainment scaling (GAS) (Figure 1 ), may better reflect goals that are important for individual treatment success. 22, 34, 35 GAS was developed by Kiresuk and Sherman 35 to evaluate individual and group outcomes in mental health services. The theory supporting the GAS procedure questions the assumption that a universally acceptable outcome measure exists due to the variety of goals that are meaningful to individual patients.

The stages of the GAS process 22 are illustrated in Figure 1 . In the first stage, three to five goals are identified during the patient interview to establish an agreed upon set of priority goals following the SMART principle 36 (specific, measurable, achievable, realistic/relevant, and time-based). These goals are weighted for importance and difficulty using a 4-point scale ( Table 1 ). The weight for each goal is then calculated (weight = importance  difficulty). The clinician and patient define the expected outcome, for each goal. The scores are then converted to a GAS T-score, which provides a numerical value for the degree to which patient-initiated goals have been achieved. 22, 35 A GAS T-score of 50 means that the expected outcome was achieved, while a score less than 50 indicates performance below the expected outcome and a score greater than 50 indicates performance exceeding the expected outcome. 37 Healthcare providers routinely apply goal setting in clinical practice; however, GAS differs in that the goals are both quantified and patient-initiated, rather than entirely qualitative and providernominated. 21, 38 Furthermore, care focusing on an individual's goals, such as GAS, may facilitate patient-centered care. GAS has the potential to increase provider and patient focus on preferred activities and aid in collaboration to achieve an individual's goals. 39 GAS may be particularly applicable in heterogeneous patient populations with complex presentations encompassing varied emotional, physical, and social domains. 34 Therefore, GAS may be an ideal outcome measure for healthcare providers to use in the management of patients with chronic LBP. GAS has been widely applied to chronic and disabling conditions 34, 40 ; however, only recently has it been used to address the problems associated with chronic LBP. 21, 37, [41] [42] [43] [44] [45] Therefore, the objectives of this systematic review were to (a) examine the characteristics and rigor of published studies of GAS in the rehabilitation of patients with LBP, (b) describe how GAS has been applied in patients with LBP, and (c) evaluate the responsiveness and validity of GAS as an outcome measure in patients with LBP.

2 | METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 46 This study had no prepublished or registered protocol before commencement.

A systematic search of the literature was performed by a single investigator (DDH) using CINAHL, PubMed (Legacy), and MEDLINE databases between the years 1968 and 1 September 2020. We limited the results to those in the English language using human participants.

The following keywords were combined to perform the search: ("goal attainment scal*" OR "goal attainment procedur*" OR "goal scal*" OR "goal attainment scor*" OR "goal achievement") AND ("low back pain" OR "lumbago" OR "spinal disorders"). Additional hand searching was completed by scanning the reference lists of included articles.

The following inclusion criteria were used to select relevant articles from the search results: (a) GAS as the primary intervention and/or outcome; (b) was applied to a patient population with LBP; and (c) receiving rehabilitation by physical therapists either alone or as part of a multidisciplinary rehabilitation team. Articles were excluded if (a) the article was an opinion paper, editorial, or non-peer reviewed, (b) GAS was not an outcome or treatment, (c) the article was not written in English, or (d) LBP was not a primary diagnosis. Study screening for eligibility was completed independently by two investigators (DEH and DDH) who first screened all articles by title and abstract and then finally through a review of the remaining full-text articles. All discrepancies were resolved by consensus. Two independent raters (DEH and DDH) independently determined the levels of evidence of each article using the Oxford Levels of Evidence 47 and rated each of the included articles for quality using the Newcastle-Ottawa scale for cohort studies (NOS) 48 and for reporting transparency using the STROBE statement checklist. 49 The NOS is a 0-to 10-point scale used to assess the quality of cohort studies with higher scores indicating higher quality. 48 The NOS shows generally fair intra-rater reliability and excellent test-rest reliability. 50 The STROBE statement checklist is a 22-item binary (yes or no)

checklist that provides guidance for reporting observational studies. 49 This tool was chosen as a supplement for NOS to describe the reporting quality 51 or the comprehensiveness and clarity of reporting of the studies. Any discrepancies in scoring were discussed until consensus was reached.

Data from the included studies were synthesized narratively as quantitative analysis was not appropriate given the variability in the included studies. The aim of the narrative synthesis was to summarize the study characteristics and the application of GAS procedures and their use in measuring patient outcomes in patients with LBP. To analyze the agreement between raters (DEH and DDH), percent 

The initial query of CINAHL, PubMed, and MEDLINE produced 247 articles, and an additional 1 article was identified through hand searching.

After duplicates were removed, 221 articles were screened for eligibility.

Screening titles and abstracts removed 213 articles, and full-text review removed an additional 1 article. Therefore, seven articles met the eligibility requirements for inclusion in this review ( Figure 2 ). LBP. All studies investigated GAS as an outcome measure, while one study 45 also considered GAS as an intervention. Physiotherapists 37, 44 applied GAS in two of the seven included studies, while four studies indicated that GAS was applied by an unspecified provider 42, 45 or "therapist," 41,52 and one was completed by an occupational therapist. 21 Those studies that did not specify the provider were composed of multidisciplinary teams that include physical therapy, occupational therapy, and/or psychology; therefore, the term "therapist" may be used to describe any of these providers.

These studies have several limitations, including the use of observational cohorts with no comparison group, deviations from standard GAS procedures, and lack of description of formal training for clinicians. One study 45 examined the therapeutic efficacy of GAS and showed improvements in GAS scores following intervention. However, the study was performed in patients (72.4% who had LBP) with poorly defined chronic pain (eg, missing cause or duration of pain). In addition, the majority of studies using GAS were completed in research settings outside the United States. 37 Walking tolerance was a significant predictor of GAS score change.

Self-efficacy made a significant additional contribution.

The use of patient-relevant outcomes with GAS showed significant achievement of personal goals at 6 months follow-up, following a CBTbased pain management program. Self-efficacy and walking tolerance were significant predictors for achieving personally important goals. Therefore, focus on enhancing self-efficacy and optimizing walking tolerance might be important in pain rehabilitation programs.

Williams and Steig, 1986, USA Mullis and Hay 43 found that GAS was able to discriminate those who improved and who did not improve and those that did not and GAS was moderately correlated with general health status (r = 0.40). GAS has been demonstrated to be associated with patient satisfaction (correlations ranged from r = 0.29-0.88). 21, 42, 43 Significantly, GAS was found to be more associated with patient satisfaction than pain and physical function outcome measures 21 and may account for up to two times the variance. 42 In addition, while GAS is generally considered an outcome measure, it may have a positive therapeutic effect and impact on outcomes as GAS accounted for 24.7% of the variance in improvement following intervention. 45 

Levels of evidence are included in Table 2 41 Hazard et al 21 Hazard et al 42 Mannion et al 37 Mullis et al 44 Oliver et al 52 

Percent agreement

are included in Table 2 and ranged between 4 and 8, which represents medium to high risk of bias, 55 Specifically, a single study scoring an 8, 45 four studies scoring a 6, 41, 42, 45, 52 to studies scoring a 5, 21,37 and a single study scoring a 4. 43 Reporting transparency data from the STROBE checklist are presented in Table 3 . The greatest threats to reporting transparency were found in the following items: 3 "State specific objectives, including any prespecified hypotheses" (missing in six of seven studies), 9 "Describe any efforts to address potential sources of bias" (missing in six of seven studies), 13(c) "Participants: This systematic review identified several highly transparent studies that found the following: patients with LBP are able to identify and set individualized goals during GAS. 43,44 GAS may be more sensitive to change 37, 41 and may measure different aspects of the patient experience as compared with fixed-item patient-reported measures. 37, 41, 52 In addition, the GAS may have a therapeutic effect while improving patient outcomes 45 and is associated with patient satisfaction. 21, 42 Previous research indicates that active patient involvement in establishing physical therapy goals, as is done in GAS, positively influences treatment outcomes and patient perceptions regarding quality of care. 56 In addition to facilitating cooperative goal setting, 57 GAS also impacts patient motivation 22, 45 ; therefore, healthcare providers may want to include GAS in their management of patients with chronic LBP. Furthermore, GAS has been used to asses patient response to cognitive behavioral approaches, 37 practice; however, the process is highly variable 58 with goals that are traditionally provider generated. 59 Furthermore, GAS procedures (approach and scale, Table 2 ) vary greatly and the time required to administer GAS for patients with LBP in clinical practice is unknown.

This review found five different procedures among the seven included studies. This variability highlights the need for a standardized approach and training for clinicians applying GAS, which will allow for greater comparability of outcomes across studies and facilitate communication among clinicians.

Hurn et al also found that there was significant variability in who administered GAS procedures in the rehabilitation of patients with pediatric, geriatric, cardiac, and neurological disorders, as well as for patients with chronic pain. 34 69 Because it assesses "achievement of "treatment intentions and goal attainment," GAS has been recommended as an adjunct to address the inherent limitations of standard outcomes measures. 70 Furthermore, GAS provides a structure for provider and patient collaboration on goal setting and achievement, 34 which may result in increased patient participation and adherence in their rehabilitation. 71 

This review has several limitations. The possibility of study identification bias is present because only articles in English were reviewed. 72 Several concerns regarding the use of GAS have been identified, including methodological inconsistency, scale variation, inconsistency in selecting expected outcomes, and difficulty with specifying specific measurable outcomes. 73, 74 This was true in the present investigation as the majority of the studies were observational cohorts with inconsistent applications of GAS.

Based on this review, GAS shows promise as a patient-centered measure that may be more responsive to change than traditional outcome measures. However, GAS has not been fully developed and validated for use in patients with LBP during rehabilitation. In order to meet the needs of healthcare providers and the impact of LBP on patients, GAS requires further development and evaluation. This review suggests that GAS may have the potential to provide an outcome measure that is more meaningful to patients with LBP than those currently used.

This type of measure would also support the therapeutic alliance and collaboration between patients and providers, which facilitate successful outcomes. The funders played no role in the design, conduct, or reporting of this study.

The authors declare no conflict of interest. of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

The corresponding author, Douglas Haladay, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

https://orcid.org/0000-0002-9077-7176

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