Who’s goal is it anyway?

Goal setting is well accepted amongst healthcare workers and is included in guidelines in the management of chronic low back pain (CLBP). Most self-management programs, aimed at motivating a person to change behaviour to achieve a specific outcome, include goal setting. The majority of clinicians agree that goal setting is important and think they are doing it well[1]. It just needs to be SMART- specific, measurable, achievable, relevant and timely. Tick those boxes and we are on our way, the patient has a plan to follow and things should get better. So if we are doing goal setting why isn’t the patient with chronic low back pain able to move on, self-manage and return to life?

There are two main theories that underpin goal setting theory and practice; self-determination and self-efficacy. According to self-determination theory[2], an individual’s motivation is enhanced if the goal meets the intrinsic needs of the individual. Motivation to engage in the process is increased when an individual works on goals that are directly important to them, with a greater likelihood of behaviour change. According to the theory of self-efficacy[3], a person’s perception of their ability to perform a task or change behaviour determines whether they will initiate that task and how motivated they will be to maintain that task or new behaviour, irrespective of obstacles.

When we compared CLBP patient goals and treatment goals reported by clinicians, we found that treatment goals do not align themselves with patient goals[4]. Is it any wonder then that patients do not adhere to treatment plans? When asked about goal setting in CLBP, physiotherapists reported that they thought it was important to do and the majority set goals to facilitate self-management[1]. Yet only 10% of physiotherapist allowed the patient to independently set the goals. How much buy-in will the patient really have in self-management if the treatment is set and led by the clinician?

We investigated the effectiveness of a patient-led goal setting approach combined with education in CLBP[5]. The distinct feature of patient-led goal setting was that the patients led the goal setting not the clinician. The most common types of goals ranged from activity based (eg walk home three times per week, start dancing class), work tolerance (eg liaise with supervisor in regard to work hours, schedule regular movement breaks), coping skills (eg use meditation app daily, thought diary) relationships (eg. discuss chronic pain with partner, schedule in coffee with friend) and sleep (eg stop using computer/phone 2 hours before going to bed, relaxation exercise before going to bed). The patient also led the development of strategies to reach their goal and undertook the strategies independently. The clinician’s role was to guide the strategy development and provide feedback over 5 fortnightly sessions. Our results showed that patients involved in the patient led goal setting significantly improved in all outcomes: disability, pain intensity, kinesiphobia, quality of life and pain self-efficacy. All of these improvements were maintained at 12 months.

We hypothesise that there are several mechanisms for this change. The neuropsychologicaleducation; explaining the biopsychosocial aspects of chronic pain and the principles of neuroplasticity and its relevance in chronic pain, provides a foundation for belief shift, reduction in fear avoidance and behaviour change – the patient’s new understanding of their pain may reduce the avoidance of activities and associated distress. By allowing the patient to lead the goal setting and take ownership of the goals, the intervention focuses on what is most important to the patient. This has the potential to harness the patient’s motivation and facilitates their involvement in their own management. The mastery of the skills that occurs through implementing the strategies, supported by the clinician, results in the patient becoming more confident in the ability to manage their CLBP and their self-efficacy improves. What was surprising in our results was the significant long term improvement in pain intensity – not found in other interventions aimed at behaviour change.

So it may be that the process by which we set goals is the key to the management of CLBP. For successful patient-led goal setting to occur the traditional power play between the clinician and patient is challenged. The patient becomes the expert in what the goal should be and how to achieve it- it is their life and well-being after all. The clinician becomes the guide, providing advice on what strategies are evidenced based as well as feedback and assistance in problem solving when barriers to goal achievement crop up. This change in the patient clinician relationship may be challenging for those clinicians set in the traditional therapeutic alliance where clinicians know best and are the expert. Patients’ expectations that the clinician will have the answers and fix them needs also to be challenged. The therapeutic alliance between patient and clinician needs to be open and allow the patient to lead the process. Both parties need to be ready to explore all aspects of the patient and the impact their CLBP is having on their life.

By changing the way we set goals, allowing the patient to lead the process of goal setting, we may be inching towards an answer to CLBP.

About Tania Gardner

Tania is a APA titled Pain Physiotherapist, works as a Senior Physiotherapist in the Department of Pain Medicine, St Vincent’s Hospital Sydney, and has over 25 years experience in the treatment of low back pain. She completed her PhD in 2017 investigating patient-led care in chronic low back pain at the University of Sydney. Her research interests lie in chronic pain, patient motivation, goal setting, therapeutic alliance and rural/regional access to chronic pain management.

References

[1] Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Goal setting practice in CLBP. What is current practice and is it affected by beliefs and attitudes? Physiotherapy Theory and Practice 2018; doi: 10.1080/09593985.2018.1425785

[2] Deci EL and Ryan RM. ‘The “What and “Why” of Goal pursuits: Human needs and the Self Determination of Behavior. Psychol Inq, 2007;11:227-268.

[3] Bandura A. Self-efficacy: Toward a unifying theory of behavioral change. Psychol Rev, 1977; 84(2): 191–215.

[4] Gardner T, K Refshauge, J McAuley, S Goodall, M Huebsher, L Smith. Patient led goal setting in chronic low back pain— What goals are important to the patient and are they aligned to what we measure? Patient Education and Counseling 2015; 98:1035–1038

[5] Gardner T, Refshauge K, McAuley J, Goodall S, Hübscher M, Smith L. Combined education and patient-led goal setting intervention reduced chronic low back pain disability and intensity at 12 months: a randomised controlled trial. Br J Sports Med 2019; 0:1–9. doi:10.1136/bjsports-2018-10008