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Goal setting revisited

Merryn Dowson takes a fresh look at the use goals in neuro-rehab amid new and emerging approaches.

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Goal setting is always a hot topic in neurorehabilitation – it has, in many ways, become much more than the sum of its parts and, as a concept, it is saturated with literature.

There is frequently new research evaluating components of goal setting or describing emerging ideas in the field, and this can be difficult to navigate, even with all the time in the world.

As clinicians, however, there is rarely ever any spare time at all. If we listen to what we are told about how important goal setting is for our service users and teams, we need to know exactly what it is, why it matters, and how we can do a good job of it.

Goal setting, simply, is concerned with figuring out what we would like to accomplish. This is apparent in so many factions of our daily lives, from thinking about our career aims to writing our day’s to-do list.

If we don’t know what we want to work towards, we might go from job to job in life with no real direction, or we might get to the end of a day and realise that we haven’t really accomplished anything.

Setting goals keep us focused on what is meaningful to us and allow us to make short-term plans towards achieving it.

This is no different in neurorehabilitation. When someone has a brain injury, they might so often feel that they just want to get “better” and for life to get “back to normal”.

What does that really mean? How do we quantify “better” and “normal” and, more importantly, what plans can we make to work towards that? Instead, it is more useful to speak with a patient about, “What specific differences to the current situation would improve your life and wellbeing?”

In this instance, a patient’s definition of “better” might really mean “I want to be able live independently again”.

This is a much clearer aim and, as such, can be set as a goal for the patient’s rehabilitation.

An interesting part of this discussion is reference to “the current situation”, referring to the extent to which someone is able to function in daily life and participate in essential and meaningful activities.

How do we quantify this? Goal setting literature suggests that this should be based in a functional assessment of which there are many different types, such as the International Classification of Functioning, Disability & Health (ICF).

They are designed to consider each aspect of individual and rate their level of impairment in those areas, using standardised assessments, patient report and observations from family members.

The results of such an assessment can then offer a comprehensive understanding of what might be the most meaningful areas of a person’s functioning to address during the goal setting process.

Once the foundations of a goal have been set, we can then start to think about how to measure progress in that goal.

Our first instinct is possibly marking a goal a either “achieved” or “not achieved” similar to crossing a task off a to-do list – it is quick and satisfying.

However not all goals, especially those in neurorehabilitation, are so black and white, and instead we need to look at the grey.

To do this, we can measure goal achievement using Goal Attainment Scaling (GAS) which centres around a set of scaling stages to record the possible outcome of a goal, following this framework:

+2                    Considerably more than achieved

+1                    Slightly more than achieved

0                      Goal situation

1                      Slightly less than achieved

2                      Slightly more than achieved

Using this scale, a single goal can be rated in its success on a spectrum rather than a “yes” or “no” approach, affording patients greater chance of success but also better mapping a patient’s journey within their rehabilitation.

After setting a goal and defining its stages, you are left with an aim for the future. There is something on the horizon that everyone is heading towards: the patient, their family and their team.

Next we need to think about how we get there. This is where everyone around a patient thinks about the steps that they will individually take towards getting a patient to that goal.

For example, if a patient has a goal to be able to walk without support from a family member, their physiotherapist might set themselves an objective of working with the patient on developing the ability to use a walking frame, while an occupational therapist might set their objective as modifying the family home to install supports to aid the patient’s mobility. Everybody defines their “to-do list” for that goal.

These processes are many and complex to complete manually. This was only too apparent within our paediatric neurorehabilitation service, Clinical Neuropsychology Services Ltd.

Whilst working towards our target of improving goal setting within the service and clients’ teams, it became clear that there was so much to understand and so little time within a normal working week of client appointments, meetings and the rest to do it all by hand.

As a result, with the help of a patient software developer, Goal Manager was developed to streamline all of the important goal setting components into one process.

It facilitates the completion of a functional assessment whose results form the foundations of goals measured through GAS, before allowing interdisciplinary professionals to log on from wherever they are to update their individual objectives for each goal.

Goal Manager was originally developed to improve our service however was soon requested by our colleagues and has subsequently grown into a much larger project.

As a result, we have learned a great deal about goal setting along the way.

Over a series of articles, we aim to present what we have discovered in a way that hopefully makes meaningful and effective goal setting more accessible to all.

We will be covering the details of functional assessments, GAS, SMART objectives and more, including stories from those who have seen the benefit of it.

Merryn Dowson is an assistant psychologist at Clinical Neuropsychology Services Ltd., the rehabilitation provider which pioneered the goal-setting app Goal Manager. For more information about the platform visit www.goalmanager.co.uk. This article was written with supervision from Dr Penny Trayner, paediatric clinical neuropsychologist.

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Osteoarthritis: breaking the cycle

Medical technology company Ottobock shares its expertise on approaches to the condition.

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Sponsored feature

Why is Cartilage Important?

Bones that come in contact with other bones are covered by cartilage at their contact points. Cartilage does not have blood vessels – it is supplied with nutrients through movement of the joint. That’s why regular exercise is so important!

Cartilage ensures that the joint surfaces move against each other in the most efficient way and with little friction. It absorbs shock, cushioning the joint, and distributes the forces acting on the joint.

If cartilage is damaged and its gliding properties are affected, it can no longer serve its purpose and the joints range of movement can become limited.

Typical Progression of Osteoarthritis

When osteoarthritis of the knee develops due to joint malalignment, an accident, advancing age, obesity or excessive strain, the damaged cartilage is no longer able to properly fulfil its function.

This results in pain and re­duced mobility. The affected patient instinctively assumes a relieving posture to reduce strain on the knee.

However, this often leads to new prob­lems in other places, such as the hip, and reduces the supply of nutrients to the cartilage, for which movement is required – sparking a vicious circle.

The cartilage develops cracks and begins to break down. At the same time, the bone thickens at the site of the damage.

When the cartilage layer is completely worn away, the affected bones come into direct contact and rub against each other causing joint pain and inflammation.

The thickest joint cartilage is located behind the kneecap (patella). This is an area of high stress. Osteoarthritis occurring in this area is known as patellafemoral osteoarthritis

Signs and Symptoms

There are several common symptoms that signal knee osteoarthritis. They can occur individually or together. However, with the initial onset, you may not notice any of these symptoms

When symptoms appear they usually occur in the following order:

  • Cracking in the joint
  • Pain during load bearing activities, such as carrying a heavy object
  • Pain during every day activities, such as climbing the stairs
  • Reduced mobility
  • Swelling and inflammation

Non-Invasive Treatments

Joint specific exercises: with regular exercise mobility can be maintained and muscle strengthened, ensuring the cartilage is supplied with the nutrients it needs.

Temperature: with acute inflammation, cold relieves pain and reduces swelling. Heat relaxes the muscles and tendons and increases the flow of nutrients. Heat may only be applied when the joint is not inflamed.

Creams: various over the counter products are available at your local pharmacy including gels and creams that can help relieve pain.

Orthopaedic devices (braces and supports): these are applied externally to the knee, reducing pain and improving mobility.

Lifestyle: living a healthy lifestyle can help to combat osteoarthritis. A healthy diet and an active lifestyle reduces the chance of obesity, putting less stress and strain through the knee joints.

Orthotic Options

An orthotic fitting is a key component in the treatment of osteoarthritis. It can provide the following:

  • Pain relief
  • Support daily activities
  • Support during activities that affect the joint, whether at work or during sports

Did you know?

An osteoarthritis patient takes an average of around 1,200 tablets a year to manage pain. But this can lead to damage to the stomach, bowel and liver.

An orthosis from the Agilium line is therefore a good alternative. It’s worth-while for anyone with knee osteoarthritis to test the effectiveness of the orthoses themselves.

The Agilium Line

The braces in our Agilium line are designed specifically to target the symptoms of osteoarthritis of the knee.

Each works in a different way to address the various characteristics of osteoarthritis of the knee. At the same time, we placed great emphasis on their comfort and suitability for daily use.

The Agilium Freestep, the Agilium Reactive and the Agilium Softfit are used to treat unicompartmental osteoarthritis of the knee.

The Agilium Patella is used for patients with patellofemoral arthritis.

The Agilium Freestep is used to treat OA, although it is not applied directly to the knee. Instead is worn on the foot, right inside the shoe! For targeted relieve, it alters the load-line of the knee – the point where the body weight impacts the cartilage.

The Agilium Softfit is a pull on knee brace with a textile base and single upright that stabilises and relieves the knee using a three point force system to offload the affected compartment (side) of the knee.

The Agilium Reactive also uses a three point force system to offload the affected compartment (side) of the knee. However, the innovative closure system in the upper calf provides comfort while sitting without compromising the stable position when standing.

The Agilium Patella combines a textile structure and stabilising component with a dynamic re-alignment mechanism enabling it to maintain the central alignment of the knee cap, reducing pressure behind the knee cap.

Find the appropriate brace with Agilium Select.

Visit our website or go to ottobock.com/agilium-select

If you would like to know more about any of these products please get in touch via orthoticsuk@ottobock.com or visit our website for more information: www.ottobock.co.uk

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Masturbation linked to stroke in medical case study

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Doctors in Japan have reported how masturbation sparked a bleed on the brain of a 51-year-old man; as published in the Journal of Stroke and Cerebrovascular Diseases.

Doctors at the Nagoya City University Graduate School of Medical Sciences in Japan explained that the man attended hospital after orgasming, with the sudden onset of a searing headache that lasted for around a minute. This was followed by an intense bout of vomiting.

A CT scan showed an acute subarachnoid hemorrhage in the left hemisphere.

The researchers note that masturbation causes an increase in heart rate, blood pressure, and noradrenaline plasma levels – which are likely to contribute to the risk of splitting a blood vessel in the brain and result in a hemorrhagic stroke.

The man was treated with stents and coiling, two techniques used to bolster the blood vessel and maintain blood flow to the brain, and he went on to make a full recovery.

The study authors say that they found just two other cases of masturbation-linked strokes in other scientific literature.

The Japanese man survived and was discharged after nearly two weeks in hospital in an “excellent” condition.

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Engineers develop ultrasound patch to monitor blood flow

Breakthrough could help to better predict stroke and other cardiovascular conditions earlier.

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Engineers at the University of California San Diego have developed an ultrasound patch that can be worn on the skin. It monitors the blood flow through major arteries and veins deep within the body.

It is hoped that it could help clinicians diagnose cardiovascular conditions faster. It could also help to diagnose blockages in the arteries which could lead to strokes or heart attacks.

The ultrasound patch continuously monitors blood flow as well as blood pressure and heart function in real-time. Assessing how much blood flows through a patient’s blood vessels could help diagnose blood clots, heart valve problems and poor circulation in the limbs.

For many patients, blood flow is not measured during a regular visit to their doctors. It is usually assessed after a patient shows signs of cardiovascular problems.

The patch can be worn on the neck or chest and can measure cardiovascular signals up to 14 centimetres inside the body non invasively with high accuracy.

How the patch works

The patch is made of a thin, flexible polymer that sticks to the skin.

There is an array of millimetre-sized ultrasound transducers on the patch known as an ultrasound phased array.

These are individually controlled by a computer. Another feature is that the ultrasound beam can be tilted at different angles to areas in the body that are not directly below the patch.

It can operate in two modes. In one, all of the transducers can be synched together to transmit ultrasound waves which produce a high-intensity beam that focuses on one spot.

This can be up to 14cm deep in the body.

A wearable ultrasound patch on the skin

The other mode allows the transducers to be programmed to transmit out of sync producing beams at different angles.

In being able to manipulate the beams, it gives the device multiple capacities for monitoring central organs as well as blood flow with high resolution.

When the electricity flows through the transducers, they vibrate while emitting ultrasound waves that travel through the skin into the body.

When they penetrate a blood vessel, they encounter the movement of red blood cells flowing inside. The cell movement changes how the waves are transmitted back to the patch.

This change is recorded by the patch and creates a visual recording of the blood flow. It can also be used to create moving images of the heart’s walls.

The benefits:

Sheng Xu, professor of nanoengineering at the UC San Diego Jacobs School of Engineering said:

“This type of wearable device can give you a more comprehensive, more accurate picture of what’s going on in deep tissues and critical organs like the heart and the brain, all from the surface of the skin.”

Xu added: “This is a first in the field of wearables because existing wearable sensors typically only monitor areas right below them.

“If you want to sense signals at a different position, you have to move the sensor to that location. With this patch, we can probe areas that are wider than the device’s footprint. This can open up a lot of opportunities.”

The researchers say that the easy to use patch could allow patients to wear the patch and monitor the results themselves. It doesn’t depend on a technician to read the results

The next stage

The patch is not yet ready for clinical use. The researchers are currently working on a way to make the electronics wireless as it currently needs a power source and benchtop machine.

Image credit: Nature Biomedical Engineering

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