Setting Goals and Measuring change

Objectives
To understand the purpose of setting treatment goals
To be able to write specific goals for treatment
To understand the purposes of using outcome measures
To provide information on a range of standardised outcome measures suitable for children with neuro-disabilities

Goal setting and Measuring change using the International Classification of Function ICF
Range of movement, muscle strength, sensation, spasticity (stiffness)
Standing up from sitting; reaching for a toy; holding a cup, etc.
Going to the park with family; playing with other children in school breaks; moving around school independently

Why is it important to set treatment goals?
To give children, parents and carers feedback
To give a focus to our treatment and therapy
To measure amount and type of progress in therapy
To help plan treatment and therapy
To detect progress, plateauing or deterioration

What do we need to think about when setting goals?
What are the main concerns and goals of the child or young person and their family?
Which activity limitations and participation restrictions need to be prioritised in therapy?

SMART Goals
Specific
Is the goal detailed enough, that another therapist would understand it and could assess if the child had achieved it?
Measurable
Is it possible to assess when the goal is achieved and when it is not achieved, i.e. is it measurable

SMART Goals
Achievable
Is this goal attainable for this child, is it possible?
Realistic
Is it reasonable to expect this child to achieve this goal in this time-frame?
Timed
By when am I hoping that the child will have achieved this goal?

SMART goals?
Sit up from lying down
To move from lying on the back via the right side to sitting in 6 weeks time
Reach for toys with hands when lying on back in 4 weeks
While lying on back, reach up (so elbow is straight) and grasp a toy in the midline (above chest) with right arm three times during 5 minutes of play, in four weeks.
Drink from a cup
When sitting on a chair up to a table, hold a 2 handled cup, half filled with a drink in both hands and take to mouth without spilling, by 30th November 2021.

SMART goals?
Improve walking with his walking frame by the end of the school term
To walk the length of the therapy room (4 metres) without crossing legs, using the walking frame with a carer assisting child to steer in a straight line, by end of school term.
Feed self with a spoon from a bowl
Sitting in school chair up to a waist high table, hold bowl on table with left hand and feed self using a spoon with right hand, >3 spoonfuls by 31st October 2021
To start to assist with easier dressing tasks
Push each arm into sleeve of a long-sleeved jumper while sitting in wheelchair, in 6 weeks.

Goal Attainment Scaling

Goal Attainment Scaling
A structured way to measure change using individualised child/family centred goals
Five levels of achievement

GAS Scores

An Outcome Measure is:
‘a test or scale administered and interpreted by therapists that has been shown to measure accurately a particular attribute of interest to patients and therapists and is expected to be influenced by intervention’
Mayo et al, 1994

Outcome Measures
Why should we use outcome measures?

Why use standardised outcome measures?
Monitor Change feedback for parents and children
Evaluate different therapy interventions
Accountability
Professional and Financial
Research
Treatment planning
Measure status
provide a baseline

Characteristics of Outcome Measures
Standardised: clear instructions so everyone can administer and score the test in the same way
Reliable: results are reproducible within the same rater and between different raters
Sensitive: responsive to change and stable in the absence of change
Valid: measures what it intends to measure

Gross Motor Assessments
Measures of activity
Gross Motor Function Measure GMFM
Mobility Questionnaire
Walking speed and function

Gross Motor Function Measure
Mackeith Press
Type of Measure: Observational measure of gross motor function. Assesses how much of an activity a child accomplishes, not quality of movement.
Consists of 88 items arranged in 5 dimensions: Lying & rolling; Sitting; Crawling & Kneeling; Standing; Walk, Run & Jump
Time to test: 45-90 minutes
Manual available from https://www.mackeith.co.uk/shop/gross-motor-function-measure-gmfm-66-gmfm-88-users-manual-3rd-edition-ebook/

Gross Motor Function Measure
Scoring: Each item is scored on a 4 point scale:
0 = unable to initiate (0%)
1 = initiates (<10%)
2 = partially completes (10 - <100%)
3 = completes (100%)
e.g.
3 = Supine: brings hands to midline, fingers one with the other
2 = Supine: brings hands towards midline (in front of chest)
1 = Supine: Initiates bringing hands to midline (some movement in right direction)
0 = Supine: Does not initiate bringing hands to midline
Training video available from: https://canchild.ca/en/shop

Mobility Questionnaire
van Ravesteyn et al, 2009, 2010 (DMCN 52 (2)194–199); Dallmeijer, et al, 2011
Measures mobility limitations in children with CP for indoor and outdoor activities
Response options: 0 = impossible without help
1 = very difficult
2 = somewhat difficult
3 = slightly difficult
How difficult was it for your child to, e.g.
Sit down on a bed, turn over in bed etc.
Get up from the toilet, get in/out of a car, in the shower
Walk on grass, tar, sand, barefoot, for 30 min etc.
Get off a bicycle
https://www.vumc.nl/zorg/informatie-voor-professionals/revalidatiegeneeskunde-voor-professionals.htm

Simple, quick to use….
Timed Up and Go TUG Dhote et al, 2012 child stands up, walks to line 3m away, touches target turns around, walks back to chair, sits down
Timed up and down stairs TUDS Zaino et al, 2004
Child walks up/down flight of 14 stairs

Simple, quick to use….
6 minute walk test Maher et al, 2008
10 metre walk test Chrisagis et al, 2014
Sit to stand test (5 repetitions) Kumban et al, 2013
Lateral Step Up Test Chrisagis et al, 2013
https://iaacd.net/2020/08/12/quick-gross-motor-measquick-gross-motor-measures-for-children-with-cerebral-palsy/?tx_category=cerebral-palsy&_page=3

Daily Living Skills, Participation & Quality of Life
PEDI-Computer Adaptive Test (PEDI-CAT)
Care & Comfort Hypertonicity Questionnaire
Assistance to Participate Scale
Cerebral Palsy Quality of Life CPQol

Pediatric Evaluation of Disability Inventory- Computer Adaptive Test PEDI-CAT
Children with physical & cognitive disabilities (0 – 21 yrs)
3 Functional skills domains (218 items)
daily activities, mobility and social/cognitive function
4-point scale: unable/hard/a little hard/easy
4th domain: Degree of Responsibility for 53 items
5-point scale: Adult has full responsibility to Child has full responsibility
Mid range item scored. On basis of score, computer selects next item etc. until stopping rule satisfied
Publisher http://pedicat.com
Distributor http://shop.crecare.com

Care & Comfort Hypertonicity Questionnaire CCHQ Nemer McCoy et al, 2006
Measure for caregivers about ease of caregiving and comfort of child in personal care tasks , positioning, transferring and communication/interaction
Examples of Items
Is there pain or discomfort during nappy changes?
Ease of getting in/out of wheelchair
Washing upper/lower body
Scored on 7-point scale, e.g.
always to never
very easy to impossible
https://apcp.csp.org.uk/system/files/care_and_comfort_questionnaire.pdf

Assistance to Participate Scale APS
www.canchild.ca Free to download
Assistance that a school-aged child with a disability requires to participate in 8 play/leisure activities at home or in community E.g. watch TV, play with a friend, at a playground, attend a club
Unable to participate
Participates with my assistance at all stages of the activity
Participates after I have set him/her up and help at times during activity
Participates with my supervision only
Participates independently
Predict the amount & type of adaptations/equipment necessary to enhance participation
Evaluate change in participation