Patient-Led Goal Setting

A Pilot Study Investigating a Promising Approach for the Management of Chronic Low Back Pain

Tania Gardner, BAppSc; Kathryn Refshauge, OAM, FAHMS DipPhty, GradDipManipTher, MBiomedE, PhD; James McAuley, PhD; Stephen Goodall, PhD, BSc, MSc; Markus Hübscher, PhD; Lorraine Smith, BA (Hons), PhD

Disclosures

Spine. 2016;41(18):1405-1413.

Abstract and Introduction

Abstract

Study Design. A prospective, single-arm, pre-postintervention study.

Objective. The aim of this study was to test the preliminary effectiveness of a patient-led goal-setting intervention on improving disability and pain in chronic low back pain.

Summary of Background Data. An effective intervention for the treatment of chronic low back pain remains elusive despite extensive research into the area.

An intervention using patient-centered goal setting to drive intervention strategies and encourage self-management for patients suffering chronic low back was developed.

Methods. A single group longitudinal cohort pilot study was conducted. Twenty participants (male = nine) experiencing chronic low back pain were involved in a patient-led goal-setting intervention, facilitated by a physiotherapist over a 2-month period with two monthly follow-up sessions after treatment conclusion. Participants, guided by the therapist, identified problem areas of personal importance, defined goals, and developed evidence-based strategies to achieve the goals. Participants implemented the strategies independently between sessions. Primary outcome measures of disability and pain intensity were measured at baseline, 2, and 4 months. Secondary measures of quality of life, stress and anxiety, self-efficacy, and fear of movement were also taken.

Results. Significant improvements (repeated analysis of variance P < 0.05) were seen in measures of disability, pain, fear avoidance, quality of life, and self-efficacy over the period of intervention and were maintained for a further 2 months after treatment conclusion.

Conclusion. This intervention is novel because the goals set are based on patients' personal preferences, and not on treatment guidelines. Our findings confirm that a patient-centered goal-setting intervention is a potentially effective intervention for the management of chronic low back pain showing significant improvements in both quality of life and pain intensity.

Level of Evidence: 4

Introduction

Prevalence of chronic low back pain (CLBP) is high (9.17%), and despite evidence of treatment efficacy, there is continuing uncertainty regarding the clinical significance of most interventions.^[1–5] The nature of CLBP is of heterogeneous, persistent and recurrent symptoms resulting in an array of bio-psychosocial problems that need to be managed long term.^[6] Active patient participation in the self-management of health conditions is effective for improving quality of life, functional status, and health service use.^[7] Self-management enables participants to make informed choices, adopt new perspectives, and gain generic skills that can be applied to new problems as they arise, to practise new health behaviors, and maintain or regain emotional stability.^[8]

Patients' engagement in self-management also improves when their personal needs, concerns, beliefs, and goals are focused on, rather than the needs of the systems or professionals.^[9] Patients and physicians often have differing preferences for treatment choices, based on the different values they place on outcomes.^[10] Patients who are assisted to identify the problems and goals that are important to them can make more effective health care decisions, achieve a greater sense of personal control over their health, and engage in concordant dialog with their health professionals.^[11]

Knowledge can be drawn from research into motivation and goal pursuit to inform and optimize self-management in CLBP. Self-determination theory of motivation proposes that an individual's motivation is enhanced if the goal meets the intrinsic needs of the individual.^[12] Aligned with this, self-efficacy theory proposes that a person's perceived competence will determine whether that behavior will be initiated and the degree of motivation in maintaining that behavior, irrespective of obstacles.^[13]

Goal setting is a component common of self-management programs and aims to facilitate behavior change to attain a desired outcome. Self-determination and self-efficacy are central to the mechanism behind goal setting.^[14] Using a goal-oriented approach, patients identify problem areas of personal relevance in relation to their condition, establish goals they wish to achieve, and strategies to achieve them. This goal-setting process can be assisted and supported by the health care professional (HCP); however, the patient is encouraged to independently undertake the steps toward goal achievement and increase their sense of mastery and ownership in the goal-setting skills.

A systematic review investigating goal setting in rehabilitation, including CLBP, provides insight into the complexity of goal setting and the lack of a consistent approach, making it difficult to judge the true contribution of goal setting.^[15] The degree of patient involvement in a goal-setting task often remains unclear with most studies describing goals to be set in collaboration with the therapist.^[15] Goals in CLBP are most often set around activity-based or functional goals; however, these are not necessarily aligned with the patient's own needs or priorities.^[16]

Goal setting is effective in facilitating self-management in several chronic conditions such as asthma,^[14] diabetes,^[17] heart disease,^[18] and obesity.^[19] However, little is found in the literature on the role and effectiveness of a patient-led goal-setting intervention in CLBP.

The present study aims to explore the feasibility and preliminary efficacy of an intervention using patient-led goal setting to drive the intervention strategies and facilitate self- management for patients experiencing CLBP. This approach differs from those described in the literature in that the patient's participation in setting the goal is clearly defined and it is the patient who solely sets the goal. The therapist guides the patient in developing evidence based strategies, and the patient implements these strategies independently.

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Table 1. Intervention Design: Components of the Intervention for Each Session
Intervention	Measures
Session 1
•Patient orientation	•QBPDS
•Consent	•SF36
•SMART approach explained	•DASS
•Goals and strategies determined	•PSEQ
Homework task: youtube video, read chronic pain section from participant handbook	•TAMPA
	•VAS
	•Treatment credibility
Session 2
•Chronic pain model discussed
•Review of goals, progress toward, and •barriers to achieving goals
Strategies determined
Sessions 3 and 4
•Review of goals, progress toward, and barriers to achieving goals
•Strategies
•determined
Session 5 (completion of intervention)
•Review of goals, progress toward, and barriers to achieving goals	QBPDS
•Strategies	•SF36
•determined	•DASS
	•PSEQ
	•TAMPA
	•VAS
	•Treatment credibility
Monthly follow up (3 months)
•Review of goals, progress toward, and barriers to achieving goals
Monthly follow up (4 months)
•Review of goals, progress towards, and barriers to achieving goals	•QBPDS
	•SF36
	•DASS
	•PSEQ
	•TAMPA
	•VAS
	•Treatment credibility

DASS indicates Depression anxiety stress scale; PSEQ, Pain self-efficacy questionnaire; QBPDS, Quebec back pain disability score; TAMPA, Tampa scale for kinesiophobia; VAS, visual analog scale.

Table 2. Baseline Characteristics of Study Participants
Variable	Participants (n=20)
Gender, male	45.0%
Age, years (mean±SD)	42±12.24 yrs
Length of back pain (mean±SD)	9.6±9.9 yrs
Education	64.7% tertiary, 35.3 % secondary
Employment	65% employed fulltime,
	30% employed part time/student,
	5% unemployed
Disability (mean±SD at baseline)	34 (±12.75)
Pain (mean±SD at baseline)	6.4 (±1.87)

Table 3. Mean±Standard Deviation Scores and Comparisons in Primary and Secondary Outcomes at Each Time Point
	Baseline Mean (SD)	2 mths Mean (SD)	4 mths Mean (SD)	p ^†	Difference Baseline-2 mths		Difference 2–4 mths
	Baseline Mean (SD)	2 mths Mean (SD)	4 mths Mean (SD)	p ^†	Mean Change (95% CI)	p ^‡	Mean Change (95% CI)	p ^‡
Quebec disability	34.00 (12.75)	18.10* (14.00)	15.50* (11.67)	<0.001	15.9 (11.33–20.47)	<0.001	2.6 (−2.52 to 7.72)	0.30
Pain	6.375 (1.87)	3.350* (2.08)	3.350* (2.06)	<0.001	3.03 (1.88–4.17)	<0.001	0.00 (−1.07 to 1.07)	1.0
SF36-physical	50.9 (13.71)	65.05* (15.45)	70.35* (14.23)	<0.001	−14.5 (−19.86 to 8.44)	<0.001	−5.3 (−10.99 to 0.39)	0.07
SF36-mental	59.55 (17.38)	67.50* (18.25)	71.50* (18.21)	0.001	−7.95 (−14.44 to 1.46)	0.019	−4.0 (−8.99 to 0.99)	0.11
SF36-total	55.40 (14.98)	68.30* (15.98)	72.60* (15.21)	<0.001	−12.9 (−18.82 to 6.98)	<0.001	−4.3 (−9.31 to 0.71)	0.09
PSEQ-Self efficacy	39.15 (12.73)	48.50* (9.25)	49.70* (7.30)	0.001	−9.35 (−13.99 to 4.71)	<0.001	−1.2 (−4.58 to 2.18)	0.47
TAMPA scale for kinesiophobia -fear avoidance	37.25 (7.69)	32.90* (8.07)	32.95* (7.68)	0.008	4.35 (0.99–7.71)	0.014	−0.05 (−1.78 to 1.67)	0.95
DASS-depression	3.70 (3.85)	4.35 (4.42)	4.25* (7.48)	0.78	−2.2 (−2.20 to 0.90)	0.39	0.22 (0.22–3.68)	0.03
DASS-anxiety	4.50 (5.81)	3.40 (3.55)	2.40* (3.10)	0.04	1.1 (−0.95 to 3.15)	0.28	1.0 (−0.39 to 2.39)	0.15
DASS –stress	7.20 (3.64)	7.10 (5.59)	5.05*(4.12)	0.02	0.1 (−1.94 to 2.14)	0.92	2.05 (0.30–3.80)	0.02
Treatment credibility score	18.61 (3.15)	18.75 (4.14)	18.08* (4.46)	—	—	—	—	—

*Significant change from baseline (P<0.05).
^†Repeated measures.
^‡Paired-sample t test.

Table 4. Examples of Goals and Treatment Strategies
Physical Activity	Examples of Goals Set	Examples of Strategies Developed
	1. less tightness during cool down''	i. Specific stretches
	2.''Increase climbing sports''	ii. Pace return to climbing-establish baseline level
		iii. Increase activity by 5 min each week
	3.''walk home 3 times a week''	i. Walk home from earlier train station 2x week
		ii. Recommence weekend walk
	4. ''get involved in martial arts again''	i. Research gentle version of martial arts
		ii. Schedule martial arts class
		iii. Attend class x2/week
	5.''jog 30–40 min, low to moderateintensity''	i. Jog from home to work x2/week
		ii. Chose different parks/routes
		iii. Keep track of distance and time
		iv. Buy armband for ipod
		v. Schedule 3 sessions, OK if achieve 2
		vi. Leave work on time
	6.''start yoga	i. Buy flexi-membership card after next pay cheque
		ii. Pick favorite class and schedule it
		iii. Think of contingency plan
		iv. Take clothes to work
		v. Talk to yoga teacher before class re back pain
		vi. Pace self at class
	7. ''minimize pain whilst hiking across South America''	i. Research types of activities during trip
		ii. Schedule 1–2 hikes weekly with partner prior to trip start 5 km, increase distance by 1km each week
		iii. Increase frequency as trip approaches
		iv. Rethink itinerary to avoid prolonged sitting/standing
	8. ''be able to put socks on in the morning''	i. Specific stretches
		ii. Schedule stretches
Workplace	1. ''decrease pain at work whilst sitting''	i. Short term: take cushion into work
		ii. Long term: speak to colleague about new chair
		iii. Research best set up practice
		iv. make clear solution/ideas pre speaking to boss
		v. Find time to speak to boss and colleague re setup
		vi. Define needs clearly
		vii. Rearrange office space
		viii. Test solutions
		ix. Email solutions to boss pre meeting
		x. Research chair costs
		xi. Attend work in regular hours
	2. ''improve workplace tolerance''	i. Regular breaks, every hour acceptable to achieve 75%
		ii. Alternate days at work from home/workplace
		iii. Regular breaks every 30 min
		iv. Ergonomic assessment
		v. New chair and standing station at work
		vi. Voice activated software
		vii. Check upper back/neck posture with new ergonomic equipment
Coping skills	1.''accept/understand pain''	i. Watch you tube video
		ii. Read handbook
		iii. Research chronic pain- books/internet Thought diary
	2.''reduce stress with pain''	i. Watch you tube video
		ii. Read handbook
		iii. Thought diary
	3.''not allow pain to dictate my mood''	i. Gain knowledge on pain and its connection to my moodhandbook and video
	4.''Improve mood''	i. Read book and watch video
Relationships	1.''improve relationships with partner''	i. List what I need from partner
		ii. Educate partner re chronic pain
		iii. Address alcohol intake
		iv. Contact AA- ? partner support group for info/ideas of how to address
	2.''reduce stress at home with housemates''	i. List issues in preparation for discussion with housemate
		ii. Organize 1 outing with new housemate
	3.''improve relationship with daughterreduce stress in home environment''	i. Talk to partner
		ii. Meal plan/grocery plan
		iii. Calendar system with alert
		iv. Email system with partner
Sleep/energy	1.''get a full nights sleep''	i. Prostate check- organize GP appointment
	2.''improve energy levels''	i. Mindfulness before bed
		ii. See GP
		iii. Blood tests
		iv. Improve sleeping habits -regular bed routine
		v. Improve diet -research information
		vi. Improve B12 levels with diet
		vii. Food plan, plan groceries and cook x4/week
	3.''increase energy- increase social activity''	i Organize brunch, go to movies, talk to work colleagues

Table 5. Goal Attainment at 2 mths (Post-treatment)
Progression of Achievement (Likert Scale)	0	1	2	3	4	5
	(Not Achieved)		(Working Toward)			(Achieved)
Total no. of goals (n=52)	2 (3.8%)	5 (9.6%)	5 (9.6%)	20 (38.5%)	13 (25%)	7 (13.5%)
Physical (n=23)	2 (8.7%)	2 (8.7%)	1 (4.0%)	8 (34.8%)	5 (21.7%)	5 (21.7%)
Workplace tolerance (n=9)				6 (66.7%)	2 (22.2%)	1 (11.1%)
Coping skills (n=7)			1 (14.3%)	4 (57.1%)	2 (28.6%)
Relationships (n=3)		1 (33.3%)	1 (33.3%)	1 (33.3%)
Sleep/energy (n=2)				1 (50%)	1 (50%)
Other (n=8)		1 (12.5%)	3 (37.5%)	2 (25%)	1 (12.5%)	1 (12.5%)