The Art of Therapeutic Goal-Setting

When it comes to formulating your management plans, the most successful plans are where a clinician is able to successfully link the therapeutic goal to the client's goal.

When clinicians fail to link the therapeutic goal to the client's goals,

they run the risk of a treatment plan failing.

When this happens,

that's on us...

Attempting to fast-track this part of the consultation & formulation process, by simply dictating a program is actually a fast-track to failure.
(ie: "You have XYZ pathology, do ABC exercise, because I said so.")

What this may look like in the consultation is a lack of discussion with the client regarding their movement/exercise history, their likes/dislikes in relation to movement etc. Which is then usually followed by a brief few minutes (if that!) of being given a few generic exercises right at the end of the consultation.

If this is your approach, I pose this question;

If a clinician pays little attention to a treatment intervention or fails to communicate the importance of it.

(eg: exercise therapies)

How can we expect a client to see the intervention as meaningful or important as part of their recovery & management?

Client Goals vs Therapeutic Goals
What's the Difference?

The client's goal is what they want to achieve.

For example, this may be returning to running, engaging in activities of daily living independently and so on...

Our therapeutic goals are the physiological &/or psychobehavioural changes we are seeking from our therapeutic exercise prescription, in order for our client to achieve their goals.

For example, this may be increasing the stiffness &/or energy storage-release capacity of the Achilles tendon to sustain 10km running loads 3 x per week.

Our therapeutic goal is how we get from where they are, to where they want to be.

Clients tell us WHAT

We show them HOW

For a clinician to formulate the therapeutic goal(s) there are a number of elements we must explore.

What

The first step to formulating our therapeutic goal is figuring out what we are dealing with.

This involves arriving at a diagnosis (if there is one - remember we don't always need one!).
Secondly, we need to identify the capacity gap that our therapeutic intervention needs to overcome. In other words, what their current capacity is relative to their functional goal.

Why

Another piece of the puzzle is identifying why the problem has developed in the first place.

In this we need to explore the mechanism/s of action, causative factors and potential underlying risk factors that have lead to the development of the problem.
If we neglect to explore why the problem has developed in the first place, we run the risk of either a) not reaching a successful treatment outcome &/or b) perpetuating the injury.

How

This is where we get to artfully apply the science.

Linking our WHAT to their WHY

In order for us to successfully execute the how there are a number of elements we need to explore, which are arguably what will set us up for success.

Education - what knowledge gaps exist that are potential barriers for our client to proactively engage in their management plan?

There may be a number of knowledge gaps that exist for an individual, ranging from their level of health literacy, their understanding of the reasons why the pathology/problem has developed, efficacy of treatment interventions,

Goal-Setting - micro-goals vs macro goals.

ie: short-term &/or between consultation goals vs the overarching goals of the individual.

Not only does goal-setting assist us in working towards our variable metrics of success, it also allows us to cultivate a sense of meaning with the individual in relation to our therapeutic interventions.

Application of Load - when managing musculoskeletal pathologies we are often required to facilitate specific tissue adaptations in order to help the individual achieve their goals.
In many instances there is a fairly broad stroke we can apply that will help in this regard. Other times, we may need to be more targeted in our therapeutic exercise prescription to do this.

As with any therapeutic intervention we implement, clinicians have a responsibility to understand what the effects of our exercise prescription will be.

Linking Therapeutic Goals to Client Goals

There are typically 5 stages in the development of a rehabilitation management plan.
During each stage there are crucial elements we must explore, if we want to gather the relevant information to formulate an individualised & meaningful management plan.

Consultation

We begin with the consultation that primarily focuses on the subjective information relevant to the next steps.

During the consultation we are focusing on building rapport, identifying the client's goals, exploring their relevant history, identifying possible barriers, gaining an understanding of their expectations and also, arriving at a diagnosis (if there is one).

Formulation

During the formulation process, this is where we begin to link the client's goals to our therapeutic goals.

Therapeutic goals are the physiological &/or psychobehavioural changes we are seeking from our therapeutic exercise prescription, in order for our client to achieve their goals.

We've gathered a range of relevant subjective & objective information, that we will then put into practice, with consideration of the following; type of injury, mechanism/s of injury, stage of healing, psychobehavioural barriers, movement & health literacy, exercise selection, therapeutic exercise dosage, equipment & environment.

Education

At this point we have formulated our plan to link the client's goals to our therapeutic goals.
Now it is our job to cultivate meaning, essentially getting out client's 'buy in'.

We do this by reinforcing our WHAT, WHY, WHEN & HOW.

What exercises will they be doing?

Why are they performing these specific movements? - this is the crucial piece of information we need to convey.

When will they be performing the exercises?

How will they be performing the exercises?

Whilst effective education is imperative, it's important to not get ourselves lost in over-explaining. 
That is, we want to keep things as simple, clear & concise as possible. 

Initiation

The education and initiation phase will often occur concurrently, especially in relation to the 'how' - as this is where we will be demonstrating the exercises and having the client engage in the movements we are prescribing.

The purpose of the initiation phase is to foster the client's understanding of why we are implementing the specifics of their program, in addition to ensuring they have the knowledge and skills to execute the program safely & effectively.

You may look at the initiation phase as the 'troubleshooting' phase, before finalisation of the management plan at the end of the consultation.

Some questions to ask yourself in order to have confidence that you're ready to implement the management plan are;

Have we had open communication?

Does the client understand the whys?

Does/will the client have access to the required equipment/resources to engage in the exercises outside of the clinical setting?

Implementation

Wrapping up your consultation, you are now implementing the management plan for your client to engage in between now and your follow-up consultation.

In order for us to have confidence that the management plan will be adhered to throughout this time, you have hopefully considered that we have fostered sufficient levels of motivation from the client, we have ensured that we have created an environment where the client feels confident to engage in their therapeutic exercise prescription and we have created a review schedule to track progress and keep working towards the client's goals.

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I hope this article has given some useful insights into the nuances that exist in goal-setting and some strategies that may improve the collaboration you are able to foster with your clients.

If you would like a free resource that can help with the formulation of your therapeutic exercise planning, I encourage you to download my Movement Prescription Blueprint.

This free resource (and instruction video) can be accessed at www.progressivepodiatryproject.com/blueprint