The Importance of Goal Setting: Patient - Therapist Goal Collaboration

Patient goals.  These are the primary driving force behind physical therapy interventions.  But recently I began to wonder… why do they seem so one sided?  I had to re-evaluate how I was setting goals for my patients since coming into an outpatient setting after years of inpatient rehab.  There are very different objectives in the 2 settings.  In inpatient rehab, the goal is clear – get the patient home!  In outpatient, the goal can be much broader – I want to play tennis again, or very specific – I want to walk heel-toe.  I would write these goals for patients, along with the outcome measure-based goals for improved TUG times, FGA for balance, gait velocity, etc, but it never really felt like these goals were a real collaboration.  They felt more like my goals or ones I had to write out of obligation to the payer sources.  Of course, meeting the outcome-based goals would ultimately get the patient to move better and safer, but where’s the teamwork?  Where’s the salience?  How do you create a mutual relationship of working toward a common goal when the goals seem so… blah? 

It became extremely clear to me how real collaboration on goal setting could work when I met RM.  She was a bubbly, dynamic, young woman with MS who wanted to work on her walking.  RM told me she felt like her left leg was getting weaker recently and dragging more often causing her to trip.  Despite having MS for 11 years she could walk without an assistive device, though 6 years ago she reported she “weaned” herself off of a cane.  RM told me she tried doing the MS walk for 3 years and has never been able to complete it.  She reported that she would start the walk but that her boyfriend had to carry her on his back in order to finish.  The next MS walk was about 2 months away and RM was planning to try it again, though she was quite certain it would end the way the past ones had – with her being carried on her boyfriend’s back.  As I performed my initial assessment with her, it became painstakingly obvious to us that this needed to be her goal.  She would finish the Long Beach Walk MS 5K on her own 2 feet!  RM was not completely confident that she could actually do it - BUT together we came up with a plan that we knew would help her succeed. Being the hard-working, type-A girl that she was, she was in!  

During our evaluation I had RM perform the 6 minute walk test to determine her endurance and walking pace over a longer distance.   The continuous 6 minutes was difficult for her.  She was fatigued afterward and extremely wobbly.  She walked 310 meters in 6 minutes – not even a distance considered to be an “unlimited community ambulator” despite the fact that she worked full time at a very demanding job and did not use an assistive device or wheelchair.   Based on RM’s 6 minute walk time, it would take her over 90 minutes to complete the 5K!  And that is if she did not stop for a break and maintained the same pace for the entire walk.  What a daunting outlook when walking for only 6 minutes seemed like a challenge.  Nonetheless, together we knew she would be up for the challenge.  I devised a walking program for her that involved 5 days of walking per week with a long walk on Saturdays and presented it to her for review.  I made a calendar in iCal of the walking program and shared it with RM so we both had it on our iPhones – giving her even more onus to complete her walks knowing it would show up on my daily schedule.  I was (fairly) confident that with the walking program over the next 7 weeks and PT to work on her gait impairments, balance, and strength that her walking would be much improved and that she could (hopefully) complete the 5K!  

I’m going to save the rest of the story for a future blog – boy was that an interesting experience!  -  and get back to the point of goal setting.  My experience with RM showed me that there could be REAL collaboration with patients on meaningful goals.  When both parties are mutually invested, amazing things can happen.  RM stuck to her walking program religiously, giving me updates on her long walks over text or email.  I kept my commitment to her success by working with her 2 days a week before her work at 6:30 am – which is far out of my comfort zone – but completely worth doing to support her and help her reach goals that she actually cared about.  Now, I don’t think that we need to perform crazy sacrifices to help patients meet their goals, but when you can create a relationship of mutual commitment to the goal it is so powerful for both the patient AND the therapist.  The experience with RM made me think – I need to find this level of collaboration with every patient I work with.