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. 

In This Article

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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