Use of Goal Attainment Scaling in Inpatient Rehabilitation for Persons With Multiple Sclerosis

Article Outline

• Abstract
• Methods
  • Setting and Program
  • Participants
  • Procedure
  • Measurement
    • MS-related measures
    • Goal attainment scaling
  • The FIM and Barthel Index
  • Clinical Global Impression
  • Statistical Analysis
• Results
• Discussion
  • Study Limitations
• Conclusions
• Acknowledgments
• Appendix
• References
• Copyright

Abstract 

Khan F, Pallant JF, Turner-Stokes L. Use of goal attainment scaling in inpatient rehabilitation for persons with multiple sclerosis.

Objectives

To use goal attainment scaling (GAS) to measure clinically important functional change in persons with multiple sclerosis (MS) and to assess its responsiveness compared with standard measures used to evaluate progress in rehabilitation.

Design

Prospective, observational cohort study.

Setting

Tertiary inpatient rehabilitation unit in Victoria, Australia.

Participants

Consecutive sample of 24 persons with MS admitted for comprehensive rehabilitation program. The male-to-female ratio was 10:14, and the mean age ± standard deviation was 52.0±8.3 years (range, 37−62y). Over half (n=14 [58.3%]) had secondary progressive MS.

Interventions

Not applicable.

Main Outcome Measures

GAS scores were calculated for 5 to 10 priority goals set prospectively by each patient in agreement with the multidisciplinary treating team and compared with standard outcome measures—the FIM instrument and Barthel Index—rated on admission and discharge from the program. Patients were categorized into responders and nonresponders based on an overall clinical global impression.

Results

Of 203 selected goals, 167 were achieved at the predicted level. GAS recorded outcomes for 105 individualized goals not measured by the FIM and Barthel Index. Although all 3 measures showed statistically significant change from admission to discharge (P<.001), only GAS scores strongly correlated with the Clinical Global Impression scale (ρ=−.86, P<.001). GAS discharge scores differed significantly between the responder and nonresponder groups (Mann-Whitney, z=−3.78, P<.001). Different measures of effect size gave different results, but GAS was consistently more responsive than either the FIM or Barthel Index.

Conclusions

This preliminary study suggests that GAS is a responsive and useful outcome measure for the rehabilitation of persons with MS, providing added value to standardized outcome measurement.

Key Words: Multiple sclerosis, Rehabilitation

MULTIPLE SCLEROSIS (MS) is a common neurologic disease in young adults, affecting 2.5 million persons worldwide.¹ Persons with MS form a heterogeneous population with respect to age, stage of disease, and severity of impairment. They have many different combinations of disabilities and function in a wide variety of different social environments and support structures. Although they can benefit from rehabilitation programs,² their rehabilitation needs vary enormously, ranging from issues of bladder retraining, sexual counseling, and cognitive assessments to equipment needs, environmental modification, and vocational training.

The degree of variation poses a challenge for the measurement of outcomes from rehabilitation.³, ⁴ No single outcome measure is relevant to all patients. Small changes that may be of critical importance are often lost in global measures of disability such as the FIM instrument⁵ or the Barthel Index,⁶ and a patient and/or family may have goals beyond simply independence in activities of daily living. It is important to know whether the overall aim of intervention has been achieved from the patient’s perspective.

Goal-setting is an integral part of rehabilitation intervention, because it encourages participants to set their own goals and priorities and supports team communication and coordination.⁷ The success of a program may be usefully judged by the extent to which the intended goals are achieved.

Goal attainment scaling (GAS)⁸ is a method for rating goal achievement on a 5-point scale. It has a standardized mathematic formula to produce a single aggregated score.⁸, ⁹ It supports the evaluation of individualized outcomes from complex intervention where patients form a heterogeneous group; it also offers qualitative information regarding the goals that were set and achieved during the program.

Originally described by Kirusek and Sherman⁸ in the context of mental health intervention in the 1960s, GAS has subsequently been applied in a number of areas relating to rehabilitation including cognitive,¹⁰ aged care,¹¹, ¹² amputee,⁹ and acquired brain injury rehabilitation.¹³, ¹⁴ Although the technique has its critics, a systematic review has shown an extensive literature base to support its validity, reliability, and responsiveness as an outcome measure for rehabilitation.¹⁵ In the context of MS, GAS has been reported as useful in facilitating behavior change in a community-wellness intervention program,¹⁶ but its application as an outcome measure for inpatient rehabilitation programs for persons with MS has yet to be explored.

The objectives of this study were (1) to explore the type and nature of person-centered goals that were commonly set and achieved during the program and (2) to compare the responsiveness and relative efficiency of GAS with the FIM and Barthel Index as outcome measures for rehabilitation in MS.

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Methods 

Setting and Program 

This analysis was part of a larger prospective observational cohort study addressing the efficacy of rehabilitation in persons with MS at the Royal Melbourne Hospital (RMH), a tertiary referral center in Victoria, Australia. The study was approved by the Human Research and Ethics Committee at RMH. The methodology has been previously described.¹⁷

The MS Rehabilitation program at RMH provides an intensive interdisciplinary inpatient program, 5 days a week for 3 to 6 weeks, focused on improving symptoms such as pain and spasticity and addressing factors relating to quality of life and participation. The components of the 5-day program are shown in appendix 1.

Participants 

Consecutive patients admitted to the rehabilitation program were assessed by an independent neurologist at RMH (TK) and were included if they met the study selection criteria, which were as follows: age between 18 and 65 years, confirmed diagnosis of MS based on the criteria of Poser et al¹⁸ and cerebral magnetic resonance imaging findings consistent with MS according to the criteria of Paty et al,¹⁹ Expanded Disability Status Scale (EDSS)²⁰ scores for mobility between 2 and 8 and cognition based on the Kurtzke Functional Scale (KFS) between 0 and 2, living at home, were active and mobile in the community, and provided informed consent to participate.

Patients excluded were those who had cognition scores greater than 2 on KFS (to limit errors due to cognitive deficits) and those who were bed-bound or institutionalized.

Procedure 

The interdisciplinary team assessed each patient within 48 hours of admission to the unit. Goal-setting involved each patient (and family) and treating team. For accurate evaluation, goals should be SMART (specific, measurable, achievable, realistic, and timed). Patients selected their goals for rehabilitation with assistance from the treating team. The selected priority goals for GAS (see below) were “smartened” by negotiation with patient and family to arrive at a defined objective, which was agreed to represent a successful outcome for the program. This negotiation to establish realistic and achievable goals is not only critically important to the process of GAS but also forms a valuable part of patient and family education.

The treating team then reviewed patient progress at case conferences and documented variation in the goals attained. The end-point for evaluation of goal achievement and other outcomes for each patient was at the time of discharge from the unit, when patients returned home to the continued supervision and support of their local rehabilitation team.

Measurement 

MS-related measures 

For each patient the MS stage of disease and severity category were recorded using the EDSS levels²⁰ by 1 of 5 neurologists with a subspecialty interest in MS. The severity of MS was determined by assigning a score for each of the 7 KFS (pyramidal, cerebellar, brainstem, sensory, bowel and bladder, visual, cerebral) and a single unifying score of the EDSS quantifying disability from the 7 functional system scores. The EDSS is a 20-step scale (using half steps) ranging from 0 (normal) to 10 (death due to MS).

Goal attainment scaling 

The methods used here were similar to those of other studies.⁹, ¹¹, ¹⁴ Goal attainment was rated using a 5-point scale where 0 is the expected level of attainment if the patient receives the intended treatment program; +1 represents a “somewhat better than expected” level of attainment and +2, “a much better than expected” level; and −1 represents a “somewhat less than expected” level of attainment and −2, “much less than expected.”

A list of 5 to 10 priority goals were identified from the goal-setting procedure described above, and a “statement of expected outcome” was determined for each goal to identify the 0 score. A “discharge scoring guide” was then prepared to define the levels of attainment for each of the 5 points of the scale before treatment was commenced.⁹ An example is presented in table 1.

Table 1. Examples of a “Statement of Expected Outcome” and Discharge Guide for the Various Goal Attainment Levels

⁎Follow-up scores were at the time of discharge from the unit.

Each goal was weighted according to its importance to the patient and the anticipated difficulty, in terms of likelihood of achieving that goal on a simple 3-point scale¹⁴: “importance” was graded by the patient as either 1 (fairly important), 2 (very important), and 3 (extremely important), and “anticipated difficulty” was rated according to both the patient and the treating team’s perception of the likelihood of achieving the agreed 0 score as 1 (probable), 2 (possible), or 3 (doubtful). The product of these 2 ratings was then used as the weight for each goal.

The patient baseline scores for each goal were allocated as −1, unless they could not have been at a worse level for that goal, in which case they scored −2.⁹ For example, in goal-setting relating to achieving independent transfers, if at baseline a patient required help for transfers he/she would score −1, but if he/she were hoisted for all transfers he/she would be allocated −2, because this is the lowest possible level. At the time of discharge, each patient was reassessed to assign the level of individual goal attainment, according to the descriptions in the statement of expected outcomes and discharge scoring guide. GAS attainment levels were rated independently by the attending physician (FK) and an independent researcher (LO). In the event of disagreement, the lower level was recorded.

The composite goal attainment score (T score) based on the aggregated weighted score of each patient’s goals⁸ was calculated by an independent researcher (WB) using an automated spreadsheet¹⁴ to apply the following formula:

where w_i is the weight assigned to the ith goal, x_i is the numerical value achieved (between −2 and + 2) and ρ is the expected intercorrelation of the goal scales. This formula produces an overall average of the outcome scores, adjusted for the relative weighting applied to each score and the “expected intercorrelation” (ρ) between goal scores. Kirusek and Sherman⁸ suggest 0.3 as a typical intercorrelation (and therefore 1 − ρ = 0.7).

The FIM and Barthel Index 

The FIM⁵ and Barthel Index⁶ are global measures of independence in activities of daily living (ADLs) that are widely applied as standardized outcome measures for neurologic rehabilitation and have been shown to be responsive, reliable, and valid measures of disability in MS patients.²¹ For each participant, the treating team completed the Barthel Index and FIM scores within 48 hours of admission to the rehabilitation unit and again within 48 hours of discharge.

Clinical Global Impression 

The Clinical Global Impression (CGI)²² of the attending physician was used to assess overall treatment response and was applied as an indicator of clinically important change as previously reported by Rockwood et al.¹⁰ The CGI is a simple and robust tool, and it is used to assess complex treatments in mental health settings.²² The changes recorded by CGI correlate with changes observed with more complex scales.²³ The CGI was rated on a 7-point scale (1, very much improved; 2, much improved; 3, minimally improved; 4, no change; 5, minimally worse; 6, much worse; 7, very much worse). The CGI rater (FK) had detailed knowledge of each patient and participated in the development of the statement of expected outcome and the discharge scoring guide but was blinded to the actual GAS score when scoring the CGI.

Statistical Analysis 

SPSS^a was used for all statistical analyses. Although the GAS formula is designed to generate aggregated attainment T scores, which are normally distributed around a mean of 50, the numbers here were small, and the Barthel Index data did not sufficiently conform to criteria for normality (Kolmogorov-Smirnov >.05). Therefore, nonparametric statistical tests were used where indicated. Descriptive statistics were generated showing the frequency of patient-selected goals, collapsed into common themes. The relationships between GAS, CGI, and change in FIM and Barthel Index were examined using Spearman correlations coefficients. Differences between baseline and discharge were tested using Wilcoxon signed-rank tests. Effect size was calculated using 2 methods, both of which are used in the literature but are shown to give differing results²⁴: the Cohen d effect size (mean change/standard deviation [SD] of baseline score) and standardized response mean (SRM) (mean change/SD of change score) were compared for the 3 measures; efficiency was computed to compare the relative efficiency of the different scales in measuring change in the sample using the Barthel Index as the index measure. Although pairwise T² values are most commonly reported (T² [measure]/T² [Index measure]), we also computed pairwise z² values from the Wilcoxon signed-rank tests because of concern that results generated by parametric statistics confound responsiveness with the effect of non-normality and favor normally distributed outcomes.²⁵ Scores on the CGI were used to classify participants as responders (CGI scores of 1, 2, 3) or nonresponders (CGI scores of 4, 5, 6, 7). GAS discharge T scores and FIM or Barthel Index change scores were compared between responders and nonresponders using the Mann-Whitney U test.

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Results 

Over a 14-month period (2005−2006), 24 patients fulfilled the selection criteria for inclusion in the analysis. The male-to-female ratio was approximately 2:3 (10 men, 14 women). The mean age ± SD was 52.0±8.3 years (range, 37−62y), with a mean time since diagnosis of 11.1±5.0 years (range, 2−23y). More than half were diagnosed with secondary progressive MS (n=14 [58.3%]): 5 (21%) with relapsing remitting and 5 (21%) with primary progressive MS.

In terms of severity, a total of 11 (45.8%) patients recorded EDSS scores above 6.5. A further 10 (41.7%) had scores between 3.5 and 6.0, and 3 (12.5%) had EDSS scores of 3 or below. The mean hospital length of stay (LOS) was 18.0±14.6 days (range, 6−64d). There were 2 outlier patients for LOS; one discharged himself against medical advice at day 6, and the other stayed for 64 days waiting for completion of home modifications.

The 24 patients in the sample selected a total of 203 goals. The number of goals per patient ranged from 5 to 10. The frequency of different goals and themes, together with the discharge scores for level of goal attainment are shown in table 2. Selected goals represented the domain of activity and participation based on the World Health Organization’s International Classification of Functioning, Disability and Health.²⁶ All patients had goals related to improvements in self-awareness and pacing for managing fatigue.

Table 2. Summary of Frequency of Participant-Selected Goals (and Themes) and the Follow-Up Scores for Level of Goal Attainment (N=24)

NOTE. If the goal was achieved as predicted it was scored as a 0. If the goal was achieved above the predicted level it was scored as +1 (somewhat better than expected) or +2 (much better than expected). An achievement below the expected level was scored as −1 (somewhat less than expected) or −2 (much less than expected).

Abbreviation: ICF, International Classification of Functioning, Disability and Health.

There was common emphasis on learning, planning activity, and physical function. Twenty-three (95%) patients wanted to improve mobility, 16 (66%) chose transfer techniques, and 15 (62%) selected learning to manage spasticity and follow an exercise program for fitness.

The second major goal theme was continence. Two thirds (83%) of patients wanted to learn strategies and manage their bowels better; one half selected bladder care, and a third (29%) wanted to improve their planning and schedule for self-intermittent catheterization.

Over one half requested information on improving access to equipment and home modifications and their abilities to use them.

Of the 203 patient-selected goals, 167 (82%) were achieved at the predicted level (score, 0) or above (+1 or +2). Only 36 goals fell below the expected level of attainment (−1 or −2). These most commonly related to limited success achieved by the patients with ambulation and exercise protocols. Only 98 (48%) of the set goals fell within the domains of the Barthel Index or FIM.

Table 3 shows the patient admission and discharge scores for the GAS, Barthel Index, and FIM scales. For the sample as a whole there was a statistically significant change from admission to discharge on all 3 measures (Barthel Index: z=−3.52, P<.001; FIM: z=−3.73, P<.001; GAS: z=−4.20, P<.001).

Table 3. GAS, Barthel Index, and FIM scores for the Total Sample and CGI Responders and Nonresponders (N=24)

NOTE. Values are median (IQR). The MS participants were divided into 2 groups according to their scores on the CGI, with scores of 1, 2, or 3 classified as responders and scores of 4, 5, 6, or 7 classified as nonresponders.

Table 4 shows the Spearman correlation coefficients between the various measures. As expected there was a very close relationship between the GAS T score at discharge and the GAS change from baseline. Equally expected was a strong relationship between FIM and Barthel Index change scores. However, although there was a close relationship between GAS scores and the CGI, no such relationship was seen between the CGI and the FIM or Barthel Index.

Table 4. Spearman Rank Correlations Between Measures

⁎Significant at P<.001.

Table 5 shows the effect sizes and relative efficiency of the FIM and Barthel Index compared with the GAS score, calculated by the different methods. Although the figures vary slightly between the different methods, as previously reported, the trend across all tests is similar, with the FIM being very slightly more responsive than the Barthel Index but the GAS being more responsive than either.

Table 5. Effect Size and Relative Efficiency of the Different Measures (N=24)

A total of 17 (70.8%) patients were classified in the CGI responder group, consisting of 11 (65%) women and 6 (35%) men. The nonresponder group comprised 7 (29.2%) patients, of which 3 (43%) were women and 4 (57%) men. As might be expected, the hospital LOS in the nonresponder group was longer (mean, 22.7±18.0d; range, 8−62d) compared with the responder group (mean, 16±13d; range, 6−64d), although this difference did not reach statistical significance (t test; t=1.02, P=.32).

Figure 1 shows boxplots of GAS discharge T scores, FIM scores, and Barthel Index scores for the responder and nonresponder groups. A Mann-Whitney U test showed a statistically significant difference in the GAS discharge scores of the responders (median, 60.6; interquartile range [IQR], 56.8−61.5) and nonresponders (median, 40.5; IQR, 35.9−43.6) (z=−3.78, P<.001). There was no statistically significant or clinically important difference in responder and nonresponder scores for the Barthel Index (z=−.94, P=.38) or the FIM (z=−.35, P=.76).

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• Fig 1. 

  Boxplot of GAS discharge T scores and FIM and Barthel Index change scores for responder and nonresponder groups.

A previous study¹⁴ has reported that, in relation to a mean GAS outcome T score of around 50, a change in GAS score (from baseline to evaluation) of more than 10 was associated with a clinically significant change. In this study, all nonresponders had GAS change scores of 16 or less, whereas all responders had GAS change scores of 17 or more, suggesting a higher cutoff point.

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Discussion 

The MS patients in this study represented a range of disability and disease severity, with demographics and diagnostic characteristics typical of MS, similar to patients in other evaluated inpatient rehabilitation programs.², ²⁷ In this study, the goals selected by MS patients were typical of MS-related disability (relating to energy, fatigue, decreased mobility, incontinence, constipation, sexuality), and consistent with other reports.²⁸, ²⁹, ³⁰, ³¹, ³², ³³

We found GAS to be a useful method to evaluate outcome from an inpatient rehabilitation program for patients with MS. Once the treating team was familiar with the procedure, GAS was feasible and practical to apply, although the process (especially drawing up the discharge scoring guide) required an additional investment of time and effort over and above the usual goal-setting process. GAS, the FIM, and Barthel Index all showed statistically significant gains in function during the program. However, GAS was more responsive and showed a high relative efficiency as an outcome measure compared with the other 2 scales. Only the GAS scores showed a strong relationship with clinical assessment of global improvement (CGI). Moreover, GAS provided added value in providing qualitative information with respect to achievement in the goal areas that were most important to patients and their families. Over half of the goals chosen were in areas not included in the FIM or Barthel Index.

Study Limitations 

There are a number of recognized limitations to this study. First, it included only a small number of participants, and the outcomes address only those achieved during an inpatient rehabilitation program. Further studies are needed to assess the value of GAS in different rehabilitation settings, over a longer time period, and after patients are discharged home to ascertain the maintenance of therapeutic gains. Second, there is some recognized opportunity for bias, because treating clinicians were involved in both the goal-setting and in providing the information that informed evaluation of overall response. This is inevitably the case where GAS is used as an outcome measure in the course of routine clinical practice. In this study we attempted to minimize this bias by predefining the scoring levels for goals in a written statement before initiation of treatment. In addition, the GAS T scores were calculated by an independent researcher (WB), and the CGI was performed by the treating physician who was blinded to the GAS outcome score. Nevertheless, the possibility for some bias still remains, and the relationship between GAS outcome scores and CGI must therefore be viewed with some caution, even though other researchers have reported similar findings.¹⁰, ¹⁴

A further potential criticism of GAS is that it depends not only on the gains made during rehabilitation but also on the experience and ability of the treating team to predict outcome. The formula used to calculate goal attainment is designed such that if goal achievement is predicted accurately and in an unbiased manner, the goal attainment scores at outcome should exceed and fall short of expectations equally, and there should be an approximately normal distribution of scores about 50.⁸ In this study, the GAS outcome scores were higher than expected (median, 58.4), suggesting a tendency to underestimate the potential for gain. This suggests some need for training on the part of the team to recognize a person’s full potential for change.

We found that previous studies have varied in their approach to the interpretation of GAS. Kirusek and Sherman⁸ recommend avoiding computation of change scores for GAS, because the change over time is built into the way GAS scores are derived. The reliability of change scores therefore may be questionable, especially where there are high correlations between pretest and posttest scores.³⁴ However, some researchers⁹, ³⁵ have recorded change in GAS scores from baseline to evaluation as the main outcome and argued that such calculations are required for the evaluation of responsiveness and relative efficiency. In practice, there is a close relationship between GAS outcome and change scores (ρ=.95 in this series), so it may not matter which is used.

Finally, with regard to measurement of responsiveness, like others²⁴, ²⁵ we have found that the different methods for calculating effect size and relative efficiency of outcome measures produce quite varied results. In this series the Cohen d effect size and relative efficiency based on T² values appear to have overestimated the responsiveness of GAS, probably because of the relatively small SD at baseline and the normal distribution of GAS data. Nevertheless, the consistent trend across all the techniques in favor of GAS suggests that there is at least a small benefit in responsiveness over the FIM and Barthel Index, which is expected in the light of the wider range of goals that it reflects.

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Conclusions 

This study is a first step in evaluating GAS as an individualized outcome measure for inpatient rehabilitation programs for persons with MS. GAS was found to be a responsive and efficient measure, reflecting person-centered goals beyond simple gains in independence for ADLs. It may therefore have a complementary role to play in evaluating the effects of rehabilitation. The relationship of MS-specific measures such as the Multiple Sclerosis Impact Scale³⁶ and GAS needs evaluation. Further studies will be needed to confirm our findings in other patient populations with MS, over a longer time period, and in different clinical settings.

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Acknowledgments 

We thank Trevor Kilpatrick, MBBS, PhD, FRACP, for patient selection and recruitment; Wendy Briggs, BSc, for GAS score calculations; Loren Oskari, BSc, for CGI assessments; and Tracey Shea, BAppSci, for statistical analysis. We also thank the rehabilitation team members, including physiotherapists: Jane Searle, MSc, Julie Louie, MSc, Lisa Glasson, BSc, Lisa Williams, BSc, and Irwin Onslo, BSc; occupational therapists: Anita Major-Brown, BOT, Kate Griffen, BOT, Louisa Mogg, BOT, Natalie Woods, BOT, and Claire Pruden, BOT; speech pathologists: Bronwyn Cox, BSc, and Hayley William, BSc; neuropsychologist: Sheryl Monteath, DPsych; and social workers: Chris Bakarnis, BAppSci, and Mathew Lowe, RN, BSc. We are grateful to Tom Hale, MBBS, FAFRM, RACP, for valuable clinical advice.

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Appendix 

Appendix 1. COMPONENTS OF A TYPICAL 5-DAY REHABILITATION PROGRAM

Abbreviations: NP, neuropsychology; OT, occupational therapy; PT, physiotherapy; SLP, speech-language pathology; SW, social worker.

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