Chapter 7: How Can I Establish a Target Goal Value for My Patient?

Introduction

Therapists are routinely faced with the challenge of making prognostic judgments for their patients. For example, patients often ask questions like “Will my back pain go away completely?” or “Will I be able to walk without this limp?” These types of questions are classic prognostic questions and are some of the most difficult to answer in patient care. In our view, they are difficult to answer for two main reasons: (1) the volume of literature on prognosis is less than that for other types of clinical decisions, particularly for certain disorders, and (2) these types of questions can be very broad in nature, which make it difficult to provide a clear and concise answer.

What's Ahead

In the previous chapter we introduced three methods frequently used to identify a true or important change threshold or goal value. In this chapter we describe methods often used to establish target goal values. We use the term target goal value to denote the long-term or discharge value for the outcome of interest. An example of a target goal is as follows: To increase the patient's 20-m walk pace to 1.2 m/sec or more in 6 weeks. In this example the target goal value is 1.2 m/sec.

A Note on Terminology

For some patients seen by physical therapists a full recovery is expected. For other patients the expected recovery will be less than what one might anticipate for a person of similar age and gender in the population. In this chapter we apply the term satisfactory outcome to describe the expected optimal recovery given each patient's unique circumstance. For some patients this implies a complete recovery; for other patients it represents a state that is a less than complete recovery.

The Concept Behind This Question

A universal goal of physical therapy interventions is to optimize the functional status of patients. Central to this goal is the recognition that optimal function will be patient specific. This means that a target goal value will also be patient specific. Establishing well-conceived target goals draws heavily on the three pillars of evidence-based practice: patient's values, clinical experience, and best evidence.¹ The patient provides the physical therapist with expectations. The physical therapist considers these expectations within the unique context of each patient and seeks out the best prognostic evidence suggesting a target goal value.

Methods Used to Establish Target Goal Values

The Within-Patient Comparison Approach

The reasoning behind the comparison approach is that in an otherwise healthy person the contralateral limb provides a patient-specific expectation for the target goal value. This approach is often used to establish target values for impairments such as restricted range of motion and reduced muscle strength. A variation of the approach is also popular when forming a target goal concerning ...