Goals are commonly understood to be objective markers for success or failure. Goals win matches. Goals win trophies. In fact, ‘goals’ represent a tangible, objective demonstration of achievement in any sport and can come in many various forms. They are the reward for optimum performance and a reflection of a long and often difficult journey towards success. Goals in specialist musculoskeletal (MSK) rehabilitation are no different. They represent the ambitions of individuals embarking on a long and difficult journey towards recovery and optimal performance.
Goal setting to aid recovery from major trauma
It has been said that “goals are not a prediction of what will happen, but the intended result of some intervention” (Wade 2009), which highlights the purposeful nature of the goal setting process. So how do we go about defining the ‘intended result’ of our rehabilitation programme? Clearly, the most important contributor to this process should be the individual undergoing ‘the intervention’.
The two most reliable predictors of adherence by an individual to any form of medical treatment are said to be, firstly, the strength of their belief in the competence of the treating clinician (or team) and, secondly, the strength of their belief that the intervention that is being proposed will lead to the successful achievement of their own personal goals. Thus, the content and delivery of any rehabilitation programme must be aligned with the client’s personal goals in order to be effective – without their ‘buy in’ it will fail. Furthermore, the combined and integrated efforts of the clinical team must also be aligned towards the client’s personal goals in such a way that the client can have absolute confidence that, by engaging in the various elements of their rehabilitation programme, they will achieve these goals.
Goal setting with specialists
The prospect of achieving one’s personal goals should also motivate the individual and ‘give them something to aim at’. Goals can also motivate clinicians to work collaboratively with shared objectives, which (as we have said) is critical to the success of any rehabilitation programme. An experienced, high performing multi-disciplinary team (MDT) will combine their individual specialist inputs to ensure that all aspects of any functional goals are covered. Victims of major trauma will very often need rehabilitation input from several specialists and so the need for effective, inter-disciplinary care is paramount.
Defining goals and their scope
How then, do we go about defining these goals and what should they cover? Goals can be very broad and high-level or can be detailed and specific to certain functions or activities. They can relate to any aspect of a person’s rehabilitation, including physical, functional, social and psychological aspects of health and wellbeing. Perhaps the commonest themes in goal setting in the early stages of recovery relate to restoring mobility and to relieving pain, whilst later on they may relate more to return to work or leisure time activities.
Goals can change and may need to adapt to reflect unforeseen changes in a plan – bear in mind the famous military adage: ‘no battle plan survives first contact with the enemy’. Goals can help to identify whether an intervention is effective and is leading to the intended change, which provides opportunities to find alternative interventions if it is not. Objectives achieved towards a longer term goal can also be usefully reviewed to map progress and provide valuable reassurance of improvement, which is often much needed by those on a long and complex rehabilitation journey.
The process of goal setting for a rehabilitation programme
The actual process of goal setting can vary from the very simple, clearly stated goal to the use of more complex, validated outcome measures. Many of the latter are based on self-reported questionnaires and can include specific outcome goals set by the individual, such as in the widely used Canadian Occupational Performance Measure (COPM).
Another process is ‘performance profiling’, which is used as a coaching tool in high performance sport and can be adapted for use in rehabilitation. An individual’s specific personal goals are defined (eg. washing, going shopping, working, etc) and then broken down into the ‘constructs’ or elements of each goal that are required to achieve it (eg. balance, leg strength, confidence, etc). These elements of function then form the basis of the individual’s rehabilitation programme, which is built in such a way as to ensure that every treatment input is directed at improving their performance in one or more of the constructs and therefore the ultimate attainment of their goal. This ensures that everybody’s efforts are aligned towards the individual’s stated goals and the function needed to achieve them. Furthermore, any lack of progression towards a functional goal can more easily be attributed to a specific element (construct) of that task.
Whilst goals are often said to need to be ‘SMART’ (an acronym originating in the business world from the 1980’s), this guidance can be of limited value in rehabilitation. The ‘R’, however, is sometimes referred to as ‘resourced’ and this can have a significant impact on the goal setting process. Ideally, any rehabilitation programme should be aspirational in its objectives with few, if any set limitations to final outcome. Unfortunately, financial constraints, such as a resource-limited healthcare system or limited available legal funding can significantly influence the level at which goals are set. Thus, goals may not be set at a level that the individual might well be able to achieve, but rather at a level that is achievable with available resources.
Recovering from major trauma and goal setting
The journey to recovery following any major trauma event is a long and often very challenging one. The importance of early goal setting to help the individual to ‘map out’ their journey and to build their faith and trust in those helping them along the way cannot be overstated. The benefits of effective goal setting also extend to the clinicians and others involved in the rehabilitation process by helping to define direction, identify ‘hold ups’ and ultimately improve the quality and the efficacy of the treatments being delivered.
Specialist rehabilitation following major MSK trauma and that following injury in high performance sport share very much the same principles. The aim is always to restore function to the highest possible level and to return the individual to a level as close to their pre-injury quality of life and performance as possible. Scoring goals may, for some, be the final stage in that journey, but setting goals along the way should be part of the process for everyone.