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A systematic review to investigate the measurement properties of goal attainment scaling, towards use in drug trials

  • Charlotte M. W. Gaasterland1Email author,
  • Marijke C. Jansen-van der Weide1,
  • Stephanie S. Weinreich1, 2 and
  • Johanna H. van der Lee1
BMC Medical Research MethodologyBMC series – open, inclusive and trusted201616:99

https://doi.org/10.1186/s12874-016-0205-4

Received: 7 April 2016

Accepted: 2 August 2016

Published: 17 August 2016

Abstract

Background

One of the main challenges for drug evaluation in rare diseases is the often heterogeneous course of these diseases. Traditional outcome measures may not be applicable for all patients, when they are in different stages of their disease. For instance, in Duchenne Muscular Dystrophy, the Six Minute Walk Test is often used to evaluate potential new treatments, whereas this outcome is irrelevant for patients who are already in a wheelchair. A measurement instrument such as Goal Attainment Scaling (GAS) can evaluate the effect of an intervention on an individual basis, and may be able to include patients even when they are in different stages of their disease. It allows patients to set individual goals, together with their treating professional. However, the validity of GAS as a measurement instrument in drug studies has never been systematically reviewed. Therefore, we have performed a systematic review to answer two questions: 1. Has GAS been used as a measurement instrument in drug studies? 2: What is known of the validity, responsiveness and inter- and intra-rater reliability of GAS, particularly in drug trials?

Methods

We set up a sensitive search that yielded 3818 abstracts. After careful screening, data-extraction was executed for 58 selected articles.

Results

Of the 58 selected articles, 38 articles described drug studies where GAS was used as an outcome measure, and 20 articles described measurement properties of GAS in other settings. The results show that validity, responsiveness and reliability of GAS in drug studies have hardly been investigated. The quality of the reporting of validity in studies in which GAS was used to evaluate a non-drug intervention also leaves much room for improvement.

Conclusions

We conclude that there is insufficient information to assess the validity of GAS, due to the poor quality of the validity studies. Therefore, we think that GAS needs further validation in drug studies, especially since GAS can be a potential solution when a small heterogeneous patient group is all there is to test a promising new drug.

Trial registration

The protocol has been registered in the PROSPERO international prospective register for systematic reviews, with registration number CRD42014010619. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014010619.

Keywords

Rare diseasesGoal attainment scalingDrug trialsValidationSystematic review

Background

One of the main challenges for drug evaluation in rare diseases is the heterogeneous course of these diseases. When a disease course differs from patient to patient, traditional outcome measures may not be applicable for all patients of a certain disease. Trial designs are often limited to patients for whom the outcome measure is relevant, whereas the underlying disease mechanism may be similar in a larger group. This increases the problem of small numbers that already challenges rare disease research.

For example, in Duchenne muscular dystrophy (DMD), new drug trials until recently often used the 6-min Walk Test (6MWT) as an outcome measure. The 6MWT has been validated as a reliable and feasible outcome measure, and has been recommended as the primary outcome measure in ambulatory DMD patients [1, 2]. However, although the 6MWT may be a relevant outcome measure for boys who are not (yet) depending on a wheelchair, it is obviously irrelevant for, usually somewhat older, boys who are. This problem in DMD research has been picked up by patient representatives and researchers from all over the world [3].

As the DMD example shows, existing measurement instruments use an outcome that is not relevant for all patients, or may not be responsive enough to measure the effect of an intervention in a rare disease. However, the development of disease-specific and patient-relevant outcome measures is hampered by the small number and heterogeneity of patients with a particular rare disease. In their handbook “Measurement in Medicine” De Vet et al. [4] recommend a minimum number of 50 patients for validation studies.

A measurement instrument that can evaluate the effect of an intervention on an individual basis may help overcome the problem of small, heterogeneous populations. The importance of patient reported outcome measures is widely recognized by pharmaceutical companies and clinical researchers as well as regulators and government agencies such as FDA and NIH [5].

Goal Attainment Scaling (GAS) is a measurement instrument that is intended for individual evaluation of an intervention. It allows patients to set individual goals, together with their treating professional. The number of goals and the content of these goals may differ per patient, but the attainment of the goals is measured in a standardized way. This makes a standardized evaluation of an intervention possible, even when the patients are all in a different stage of their disease.

Goal Attainment Scaling was first introduced in 1968, by Kiresuk and Sherman [6], originally for the evaluation of mental health services. It contains a variable number of self-defined goals and very explicit descriptions of five possible levels of goal attainment that are formulated before the intervention, usually in consultation between the patient and the clinician. In the original definition, the levels are each quantified in a 5-point scale that ranges from −2 to +2, where −2 = the most unfavorable treatment outcome thought likely, −1 = less than expected level of treatment success, 0 = expected level of treatment success, +1 = more than expected success with treatment, and +2 = best conceivable success with treatment. For each goal the expected level of treatment success and at least two other levels need to be described in such a specific way that an independent observer can assess the outcome.

There is no maximum number of goals that can be set. Each goal can be assigned a weight, according to its importance to patient and/or clinician. From the scores reached after the intervention, a composite goal attainment score is computed using the following formula:
$$ T=50+\frac{10{\displaystyle \sum {w}_i{x}_i}}{\sqrt{\left(1-\rho \right){{\displaystyle \sum {w}_i^2+\rho \left({\displaystyle \sum {w}_i}\right)}}^2}} $$
where T is the composite score, wi is the weight assigned to the goali, xi is the original score for goali ranging from −2 to +2, and ρ is the estimated correlation between goal scores. According to Kiresuk and Sherman, it is safe to assume that the correlation between the goal scores is constant, and can be set at 0.3. The T-score has a mean of 50 and a standard deviation of 10, under the assumptions as proposed by Kiresuk and Sherman [6].
Besides mental health and non-medical fields such as education and social service applications [7], GAS is reportedly used in a few specific medical research areas, such as rehabilitation [812] and geriatrics [1315]. However, the validity of GAS as a measurement instrument in drug studies has never been systematically reviewed. To evaluate the usefulness of GAS in drug studies, we formulated the following three research questions:
  1. 1.

    Has Goal Attainment Scaling been used as a measurement instrument in drug studies?

     
  2. 2.

    What (drug) interventions were evaluated by studies using GAS?

     
  3. 3.

    What is known of the validity, responsiveness and inter- and intra-rater reliability of Goal Attainment Scaling in general, and in particular in drug trials?

     

In this study, we follow the COSMIN guidelines, which are the generally used and accepted standards for measurement properties evaluation [16]. This checklist contains standards for evaluating the methodological quality of studies on the measurement properties of health measurement instruments. According to the COSMIN guidelines, a health status measurement instrument can be used when its validity, reliability and responsiveness, have been tested and considered adequate. We considered GAS useful when the validity, reliability and responsiveness have been described, tested and found acceptable according to these guidelines.

Methods

We conducted a systematic review, according to the PRISMA guidelines [17].

We set up a sensitive search in Medline, PsychInfo and Embase. We searched for literature from 1968, the year when GAS was introduced by Kiresuk and Sherman [6], to May 1st, 2015. For the full search strategy, see Additional file 1. Reference lists of relevant review articles were screened for additional papers.

Papers were included in which:
  1. 1.
    Goal Attainment Scaling met the following criteria:
    • One or more individual goals were established by the patient or by one or more researchers or practitioners, either with or without input of the patient, prior to the intervention. The goals did not have to be devised by the patient/researcher, as long as the goals were individually chosen per patient.

    • The scale had to consist of at least three points (e.g. more than just goal attained – goal not attained). At least 2 points on the scale were described precisely and objectively, so that an independent observer would be able to determine whether the patient performs above or below that point.

     
  2. 2.

    The study was either a trial in which drugs are evaluated, or a study of any design in which psychometric properties of GAS were evaluated.

     
  3. 3.

    The outcome measure was the attainment of goals that had been established before the onset of the intervention.

     
  4. 4.

    The goals had been set up individually, i.e. per patient.

     
Excluded were:
  1. 1.

    Trials using an outcome measure called Goal Attainment Scaling, when the outcome measure did not meet our definition of GAS.

     
  2. 2.

    Studies in which goal setting was used as an intervention rather than outcome measurement.

     
  3. 3.

    Reviews or narratives.

     
  4. 4.

    Conference abstracts.

     
  5. 5.

    Papers published in languages other than English, French, Dutch, German or Spanish.

     
  6. 6.

    Papers published before 1968.

     

The selection of articles and data-extraction were performed in pairs of two independent reviewers. Disagreements were discussed until consensus was reached; if necessary a third reviewer acted as a referee. A standardized data-extraction form was used (see Additional file 2). We divided the included studies into two categories, i.e. drug studies, and non-drug studies in which the measurement properties of GAS were investigated.

We extracted information about the following measurement properties, defined according to the COSMIN guidelines [18]: Inter-rater reliability, intra-rater reliability, face validity, content validity, construct validity, and responsiveness. For the full definitions of the measurement properties, see Table 1. We used the quality criteria as proposed by Terwee et al. [19] to evaluate the measurement properties, as also displayed in Table 1. We chose to limit the evaluation of the quality of the measurement properties to the criteria as proposed by Terwee et al., instead of using the full COSMIN guidelines, because the COSMIN guidelines are very detailed, and many details are not relevant as these aspects cannot be evaluated for GAS, e.g. internal consistency, measurement error, criterion validity.
Table 1

COSMIN definitions [49] of the evaluated measurement properties, and their quality criteria [19]

Measurement Property

COSMIN definition

Quality criteria (+ equals good to very good quality, +/− equals intermediate quality and – equals poor quality)

Inter-rater reliability

The extent to which scores for patients who have not changed are the same for repeated measurement by different persons on the same occasion

+ ICCa or weighted Kappa ≥0.7

+/− Unclear design or method

- ICC or weighted Kappa ≤0.7

Intra-rater reliability

The extent to which scores for patients who have not changed are the same for repeated measurement by the same persons (i.e. raters or responders) on different occasions

+ ICC or weighted Kappa ≥0.7

+/− Unclear design or method

- ICC or weighted Kappa ≤0.7

Face validity

The degree to which the items of a Health Related-Patient Reported Outcome (HR-PRO) instrument indeed look as though they are an adequate reflection of the construct to be measured

+ A clear description is provided of the measurement aim, target population, the concepts that are measured, and the item selection and target population were involved in item selection

+/− A clear description of these aspects is lacking, or only target population involved, or doubtful design or method

- No target population involvement

Content validity

The degree to which the content of an HR-PRO instrument is an adequate reflection of the construct to be measured

+ A clear description is provided of the measurement aim, target population, the concepts that are measured, and the item selection and target population were involved in item selection

+/− A clear description of these aspects is lacking, or only target population involved, or doubtful design or method

- No target population involvement

Construct validity

The degree to which the scores of an HR-PRO instrument are consistent with hypotheses (for instance with regard to internal relationships, relationships to scores of other instruments, or differences between relevant groups) based on the assumption that the HR-PRO instrument validly measures the construct to be measured

+ Specific hypotheses were formulated and at least 75 % of the results are in accordance with these hypotheses

+/− Doubtful design or method (e.g. no hypotheses)

- Less than 75 % of hypotheses were confirmed

Responsiveness

The ability of an HR-PRO instrument to detect change over time in the construct to be measured

+ SDCb or SDC ˂ MICc or MIC outside the LoAd or RRe ˃ 1.96 OR AUCf ≥0.70

+/− Doubtful design or method

- Negative SDC or SDC ≥ MIC or MIC equals or inside LOA or RR ≤1.96 OR AUC ˂0.70, despite adequate design and methods

aICC Intraclass Correlation Coefficient

bSDC Smallest Detectable Change

cMIC Minimal Important Change

dLoA Limits of Agreement

eRR Responsiveness Ratio

fAUC Area Under the receiver operating characteristics Curve

Results

The search yielded 3007, 1413, and 1039 abstracts from Medline, Embase and PsychInfo, respectively. After eliminating duplicates, a total of 3818 abstracts remained for screening. In the screening phase, we excluded 3511 articles based on title and abstract, and 249 articles based on the full text. Data-extraction was executed for the remaining 58 articles (see Fig. 1). Of these 58 articles, 38 articles described drug studies in which GAS was used as an outcome measure, and 20 articles described measurement properties of GAS in other settings (Fig. 2).
Figure 1
Fig. 1

The number of articles in- and excluded in the SR

Figure 2
Fig. 2

Venn-diagram depicting the number of studies in the categories drug-studies and methodology studies, and the number of studies in both categories

In Table 2 the characteristics of the articles are presented. Most studies are trials in patients with cerebral palsy or patients with spasticity due to other causes, such as acquired brain trauma or stroke (28 studies). Also, many studies focussed on the geriatric population (15 studies). There were also some studies on autism (three studies), or neurological disorders such as MS (two studies). The remaining studies covered research areas such as family problems, goal setting in adolescent students or behaviour and psychiatric problems.
Table 2

Reported Patients, Interventions, Comparisons and Outcomes in the included studies

Category

First author

Year

Patients

Tested intervention

Comparison

Outcome(s)

Drug study with measurement properties

Cusick [29]

2006

Children with spastic hemiplegic cerebral palsy

Botox-A injections + usual care and occupational therapy

Usual care and occupational therapy

COPMa, GAS

Drug study with measurement properties

De Beurs [20]

1993

Patients meeting the DSM-III-R criteria for panic disorder with moderate or severe agoraphobia

Fluvoxamine & exposure in vivo, panic management & exposure in vivo, exposure in vivo only

Placebo with exposure in vivo

GAS, Self-report questionnaires, behavioral avoidance, therapist rating

Drug study with measurement properties

Rockwood [27]

1996

Patients with Alzheimer’s Disease of mild to moderate severity

Linopirdine

placebo

MMSEb, ADAS-cogc, PSMSd, IADLe, CGIf, GAS

Drug study with measurement properties

Rockwood [50]

2002

Patients with mild to moderate Alzheimer’s Disease

Donepezil hydrochloride 5 mg 1 daily

None

GAS, Cognition (MMSE, ADAS-cog), physical function (PSMS, IADL, FAQg), depression (CDSh, CES-Di), CIBIC-plusj

Drug study with measurement properties

Steenbeek [38]

2005

Children with cerebral palsy

BTX-A treatment of the lower extremity

None

Six-point goal attainment scaling, MASk

Drug study without measurement properties

Ashford [51]

2009

Proximal upper limb spasticity patients

BoNT-A as part of a shoulder and upper limb management and rehabilitation program which was individually tailored to the patient

None

GAS, MAS (composite spasticity score), passive function, shoulder pain

Drug study without measurement properties

Barden [52]

2014-a

Participants with spasticity following acquired brain injury

Botulinum toxin A injections

None

Dynamic Computerized Dynamometry, MAS, Tardieu Scale, Action Research Arm Test, GAS, patient disability and carer burden scales

Drug study without measurement properties

Barden [53]

2014-b

Convenience sample of adults with upper limb spasticity after acquired brain injury with a mean age of 51

BTX-A injections

None

DCD pinchl, MAS, Tardieu scale, ARATm, MHOQn, GAS

Drug study without measurement properties

Bonouvrié [54]

2013

Dystonic cerebral palsy patients aged 4–25 years

Continuous intrathecal baclofen for 3 months

Placebo

GAS, measurements of body functions (dystonia, spasticity, pain, comfort, sleep-related breathing disorders)

Drug study without measurement properties

Borg [55]

2011

Adults with a stroke that occurred >3 months before the study

Botulinum toxin A + standard care

Placebo + standard care

GAS, changes from baseline in level of goal achievement, health related Quality of Life, resource utilization

Drug study without measurement properties

Demetrios [56]

2014

Adults with post-stroke spasticity

High intensity ambulatory rehabilitation and Botox

Usual care and Botox

GAS, MASo, participant satisfaction, activity/participation measures and caregiver burden

Drug study without measurement properties

Ferrari [57]

2014

Children with hemiplegic cerebral palsy

BoNT-A injections

Placebo-injections

Body functions and structure, activity and daily life, AHAp, MAS, PEDIq, GAS

Drug study without measurement properties

Fietzek [58]

2009

Patients with Parkinson camptocormia

Botulinum toxin injections

None

GAS

Drug study without measurement properties

Lam [59]

2012

Patients with severe upper limb spasticity

Intramuscular botulinum toxin A

Saline (placebo)

Carer burden scale, GAS, Ashworth scale, passive range of movement for shoulder abduction, elbow and finger extension, Pain assessment in advanced dementia scale

Drug study without measurement properties

Lam [60]

2015

Long-term care patients with bilateral severe chronic hip adductor spasticity

Ultrasound and electrical stimulation guided obturator nerve block using 5 % phenol

Ultrasound and electrical stimulation guided obturator nerve block using saline

MAS, GAS, hygiene score, distances between the knees, passive range of motion, pain (Pain Assessment in Advanced Dementia Scale), incidence of bone fracture or infections

Drug study without measurement properties

Leroi [61]

2014

Patients with dementia in Parkinson’s disease

20 mg of memantine

Placebo

GAS, Parkinson’s Disease Questionnaire-8, Zarit Burden Inventory

Drug study without measurement properties

Löwe [62]

2006

Children with hemiplegic cerebral palsy, aged 2–8

Occupational therapy & BTX-A injections

Occupational therapy

QUESTr, average treatment effect, COPMs, GAS, PEDIt, Ashworth scale

Drug study without measurement properties

Löwe [63]

2007

Children with hemiplegic cerebral palsy

3 BTX-A injections (0, 6 and 18 months)

2 BTX-A injections (6 and 18 months)

QUEST, GAS-parents, GAS-therapist, COPM, Pediatric Evaluation of Disability, Inventory of functional skills, Ashworth scale

Drug study without measurement properties

Mall [64]

2006

Children with CP and adductor spasticity

BTX-A injections

Placebo

Knee-knee distance, hip adduction, modified Ashworth scale, GMFMu, total score and total score without aids, GAS

Drug study without measurement properties

McCrory [65]

2009

Adults with hemiplegic stroke, severe/moderately severe spasticity

Botulinum toxin for upper limbs

Placebo

QoLv, GAS, pain, mood, global benefit, MASw, disability and carer burden

Drug study without measurement properties

Molenaers [66]

2013

CP patients with lower limb BTX-A treatment, younger than 24 years of age

BTX-A treatment

None

GAS

Drug study without measurement properties

Nott [67]

2014

Community dwelling adults with acquired brain injury

Botox injections

None

GAS, MAS, TSAx, ARATy

Drug study without measurement properties

Olesch [68]

2010

Children with hemiplegic CP

BoNT-A injections + occupational therapy

Occupational therapy alone

COPMz, GAS, QUESTaa, PDMS-FMab, MTSac

Drug study without measurement properties

Rice [69]

2009

Children with predominantly dystonic CP

Trihexyphenidyl

Placebo

Global dystonia (BAD-scalead), QUEST, COPM, GAS

Drug study without measurement properties

Rockwood [70]

2006

Mild to moderate AD patients

Galantamine

placebo

GAS, ADAS-cogae, CIBIC-plusaf, DADag, CBSah

Drug study without measurement properties

Rockwood [71]

2007-a

Patients with mild to moderate AD

Galantamine

placebo

GAS, ADAS-cog, DAD, CBS.

Drug study without measurement properties

Rockwood [72]

2007-b

Patients diagnosed with mild to moderate AD

5 mg of donepezil for 3 months, thereafter flexibly dosed (5 or 10 mg)

None

ADAS-cog, CIBIC-plus, P-GAS, C-GAS

Drug study without measurement properties

Rockwood [73]

2010

Mild to moderate Alzheimer’s Disease patients

Flexibly dosed galantamine for 16 weeks, followed by 16 week open-label phase

Placebo

ADAS-cog, CIBIC-plus, P-GAS and C-GAS

Drug study without measurement properties

Russo [74]

2007

Children (3–16 years) with hemiplegic cerebral palsy

Localized injection of BTX-A and 4 weeks of occupational therapy

4 weeks of occupational therapy

Body structure (Tardieu scale, Ashworth scale), AMPSai, GAS, PEDIaj, QoLak

Drug study without measurement properties

Scheinberg [75]

2006

Children aged between 1 and 15 years with CP and clinically significant spasticity

Oral baclofen

Placebo

GAS, MTSal, PEDI, parental satisfaction of the effects of the medication

Drug study without measurement properties

Schramm [76]

2014

Patients aged 18 years or older with focal or segmental spasticity showing indication for treatment

Onabotulinum toxin A

None

MASam, spasticity pattern, pain, active hand function, FACan, gait, timed up and go test, goals and treatment parameters, general outcome parameters

Drug study without measurement properties

Turner- Stokes [77]

2007

Patients with regional spasticity following acute stroke or brain injury intervention

Serial injections of botulinum toxin

None

MAS, Associated Reaction rating scale, gait pattern, shoulderQ, functional independence (LASISao), GAS

Drug study without measurement properties

Wallen [78]

2004

Children with spastic cerebral palsy between the age of 1 and 14 years

Botulinum toxin type A injections

None

COPMap, GAS, Melbourne assessment, CHQaq, parent questionnaire, MAS, Tardieu Scale, range of motion

Drug study without measurement properties

Wallen [79]

2007

Children with CP affecting 1 or both upper limbs, aged 2–14

Single set of BTX-A injections and 12 weeks of occupational therapy

Only occupational therapy or no treatment

COPM, GAS, MAUULFar, CHQ

Drug study without measurement properties

Ward [80]

2009

Children with spasticity and/or dystonia, as classified by a rehabilitation consultant

Intrathecal baclofen therapy

None

COMPas, GAS

Drug study without measurement properties

Ward [81]

2014

Adults with focal post-stroke spasticity

Onabotulinumtoxin-A + standard of care

Placebo + standard of care

Number of patients achieving their principal active functional goal, or achieving a different goal at 24 weeks

Non-drug study with measurement properties

Bovend’Eert [37]

2011

Hospital patients with neurological disorders participating in a RCT

A motor imagery program integrated into physiotherapy and occupational therapy; refers to a previous study [82]

  

Non-drug study with measurement properties

Brown [32]

1998

Nonambulatory patients who had limited adaptive behavior

Ability-focused physical therapy

None

GAS (treatment goals and control goals)

Non-drug study with measurement properties

Fisher [83]

2002

Patients in a rehabilitation pain management program

Multidisciplinary structured educational program of physiotherapy, occupational therapy and clinical psychology

None

GAS, timed tests of physical mobility measures, MPQat, NRSau, ODQav, GHQaw, PAIRSax

Non-drug study with measurement properties

Gordon [30]

1999

Nursing-home patients (elderly and disabled)

Specialized geriatric medicine consultation

None

Effect size and relative efficiency of the Barthel Index, hierarchical assessment of balance and mobility, global deterioration scale, axis 8 (behavior) of the brief cognitive rating scale, cumulative illness rating scale and GAS

Non-drug study with measurement properties

Hartman [39]

1997

Residents of a SCU for persons with dementia

None

None

GAS, COPMay, Cognitive Competency Test, Hierarchic Dementia Scale, Leisure Competence Measure, Leisurescope

Non-drug study with measurement properties

Khan [40]

2008

Persons with MS admitted for comprehensive rehabilitation program

MS rehabilitation program

None

GAS, FIMaz, Barthel Index, Clinical Global Impression

Non-drug study with measurement properties

Palisano [21]

1993

Infants (4–24 months) with motor delays

2-h intervention session by an interdisciplinary team

None

GAS, Peabody Developmental Gross Motor Scale, behavioral objective, Movement assessment of infants

Non-drug study with measurement properties

Rockwood [31]

1993

Geriatric patients admitted to geriatric inpatient wards

None

None

GAS, Barthel Index, Functional Independence Measure, Physical Self-Maintenance Scale, Katz Activities of Daily Living Index, Spitzer Quality of Life Index

Non-drug study with measurement properties

Rockwood [33]

1997

Patients undergoing cognitive rehabilitation

None

None

GAS, Rappaport Disability Rating Scale, Kohlman Evaluation of Daily Living Skills, Milwaukee Evaluation of Daily Living, Kleinbell elimination scale and mobility scale, Instrumental Activities of Daily Living Scale, Spitzer Quality of Life Index

Non-drug study with measurement properties

Rockwood [41]

2003

Frail elderly

Specialized geriatric intervention

usual care

GAS, Barthel Index, Physical Self-maintenance scale, instrumental activities daily living, modified Spitzer Quality of Life Index

Non-drug study with measurement properties

Ruble [35]

2012

Autism patients

Psychosocial interventions

Unclear

GAS

Non-drug study with measurement properties

Ruble [36]

2013-a

Autism patients

Web based and face-to-face coaching sessions

Placebo

Goal attainment (PET-GASba), process measures such as consultant and teacher fidelity

Non-drug study with measurement properties

Ruble [34]

2013-b

Autism patients

Face-to-face, Compass intervention/face-to-face, web based compass intervention

Placebo (comparison group)

Child educational outcome, PET-GAS, language ability, autism severity, adaptive behavior, child engagement, maladaptive externalizing behavior

Non-drug study with measurement properties

Sheldon [84]

1998

Undergraduate students

Generating goals

None

A rated attainment scale, GAS

Non-drug study with measurement properties

Steenbeek [44]

2011

Children with cerebral palsy. Aged 2–13 years

Conventional multidisciplinary therapy

None

GAS, PEDIbb, GMFM-66bc

Non-drug study with measurement properties

Stolee [26]

1999

Geriatric patients

Care as usual

None

GAS, self-rated health, global clinical assessment, Barthel Index, OARS IADLbd scale, MMSEbe, NHPbf

Non-drug study with measurement properties

Stolee [22]

2012

Patients admitted to a geriatric day hospital

Geriatric day program

None

GAS

Non-drug study with measurement properties

Turner-Stokes [42]

2009

Consecutive patients admitted for rehabilitation following acquired brain injury (any cause) over 3 years

Neuro rehabilitation intervention

None

GAS, Functional Assessment Measure (UK FIM + FAM), Barthel Index

Non-drug study with measurement properties

Turner-Stokes [43]

2010

Upper-limb spasticity patients (after stroke)

Intramuscular botulinum toxin-A

Placebo

GAS, MASbg, Global Benefit, HADSbh, AQoLbi, Patient disability score, Carer burden score

Non-drug study with measurement properties

Turner-Stokes [24, 25]*

2013

Adults with post-stroke upper limb spasticity treated with one cycle of BoNT-A

Botulinum toxin A

None

GAS, spasticity, standardized outcome measures, global benefits

Non-drug study with measurement properties

Woodward [28]

1978

Families with a child between 6 and 16 years of age who was referred for academic or behavioral problems at school

Family therapy

None

GAS

Non-drug study with measurement properties

Yip [23]

1998

Patients admitted to the Geriatric Assessment and Rehabilitation Unit

Rehabilitation interventions

None

GAS (a modified version that uses a standardized menu of goals and attainment levels)

aCOPM Canadian Occupational Performance Measure

bMMSE Mini-Mental State Examination

cADAS-cog Alzheimer’s Disease Assessment Scale - cognitive subscale

dPSMS Physical Self-Maintenance Scale

eIADL Instrumental Activities of Daily Living

fCGI Clinical Global Impression

gFAQ Functional Activities Questionnaire

fCDS Cardiac Depression Scale

iCES-D Center for Epidemiological Studies Depression Scale

jCIBIC-plus Clinician’s Interview-Based Impression of Change-Plus

kMAS Modified Ashworth Scale

lDCD Pinch Dynamic Computerized Dynamometry

mARAT Action Research Arm Test

nMHOQ Michigan Hand Outcomes Questionnaire

oMAS Modified Ashworth Scale

pAHA Assisting Hand Assessment

qPEDI Pediatric Evaluation of Disability Inventory

rQUEST Quality of Upper Extremity Skills Test

sCOPM Canadian Occupational Performance Measure

tPEDI Pediatric Evaluation of Disability Inventory

uGMFM Gross Motor Function Measure

vQoL Quality of Life

wMAS Modified Ashworth Scale

xTSA Tardieu Spasticity Angle

yARAT Action Research Arm Test

zCOPM Canadian Occupational Performance Measure

aaQUEST Quality of Upper Extremity Skills Test

abPDMS-FM Peabody Developmental Motor Scale – Fine Motor

acMTS Modified Tardieu Scale

adBAD-scale Barry-Albright Dystonia scale

aeADAS-cog Alzheimer’s Disease Assessment Scale - cognitive subscale

afCIBIC-plus Clinician’s Interview-Based Impression of Change-Plus

agDAD Disability Assessment for Dementia

ahCBS Caregiving Burden Scale

aiAMPS Assessment of Motor and Process Skills

ajPEDI Pediatric Evaluation of Disability Inventory

akQoL Quality of Life

alMTS Modified Tardieu Scale

amMAS Modified Ashworth Scale

anFAC Functional Ambulation Category

aoLASIS Leeds Adult Spasticity Impact Scale

apCOPM Canadian Occupational Performance Measure

aqCHQ Child Health Questionnaire

arMAUULF Melbourne Assessment of Unilateral Upper Limb Function

asCOMP Canadian Occupational Performance Measure

atMPQ McGill Pain Questionnaire

auNRS Pain Intensity Numerical Rating Scale

avODQ Oswestry low back pain Disability Questionnaire

awGHQ General Health Questionnaire

axPAIRS Pain and Impairment Relationship Scale

ayCOPM Canadian Occupational Performance Measure

azFIM Functional Independence Measure

baPET-GAS Psychometrically Equivalence Tested Goal Attainment Scaling

bbPEDI Pediatric Evaluation of Disability Inventory

bcGMFM Gross Motor Function Measure

bdOARS IADL Older Americans Resource Scale for Instrumental Activities of Daily Living

beMMSE Mini-Mental State Examination

bfNHP Nottingham Health Profile

bgMAS Modified Ashworth Scale

bhHADS Hospital Anxiety and Depression Scale

biAQoL Assessment of Quality of Life

Most drug studies evaluated an intervention with botulinum toxin (25 studies), mainly in patients with cerebral palsy and spasticity. Baclofen was also evaluated in children with spasticity (three studies). Other drugs that were evaluated, were galantamine (three studies), donepezil for Alzheimer’s Disease (two studies), fluvoxamine, trihexyphenidil, memantine, a phenol nerve block, and linopirdine (one study each).

An overview of the reported measurement properties of GAS in the 38 drug studies and the 20 non-drug studies is presented in Tables 3 and 4, respectively.
Table 3

Reported measurement properties of GAS in included drug studies

Author

Year

Face validity

Content validity

Construct validity

Intra-rater reliability

Inter-rater reliability

Responsiveness

Cusick

2006

-

-

+

-

-

+

De Beurs

1993

+

-

+

-

+

-

Rockwood

1996

-

-

+

-

-

-

Rockwood

2002

-

-

+

-

-

-

Steenbeek

2005

-

-

-

-

+

-

Turner-Stokes

2010

-

-

+

-

-

+

Turner-Stokes

2013

-

+

+

-

-

-

Table 4

Reported measurement properties of GAS in included validity studies

Author

Year

Face validity

Content validity

Construct validity

Intra-rater reliability

Inter-rater reliability

Responsiveness

Bovend’Eert

2011

-

-

-

-

+

-

Brown

1998

-

-

-

-

+

-

Fisher

2002

-

-

+

-

-

-

Gordon

1999

-

-

+

-

-

+

Hartman

1997

-

-

-

-

-

+

Khan

2008

-

-

+

-

-

+

Palisano

1993

-

+

+

-

+

+

Rockwood

1993

-

-

+

-

+

+

Rockwood

1997

-

-

+

-

+

+

Rockwood

2003

-

-

-

-

-

+

Ruble

2012

-

-

-

-

+

-

Ruble

2013-a

-

-

-

-

+

-

Ruble

2013-b

-

-

-

-

+

-

Sheldon

1998

-

-

+

-

-

-

Steenbeek

2011

-

-

+

-

-

+

Stolee

1999

-

+

+

-

+

+

Stolee

2012

-

+

-

-

-

+

Turner-Stokes

2009

-

-

+

-

-

+

Woodward

1978

-

-

+

-

+

-

Yip

1998

-

+

+

-

-

+

Face validity

As is shown in Tables 3 and 4, face validity is reported in one article [20]. This is a drug study that evaluated the use of Fluvoxamine in patients who met the criteria for panic disorder with moderate to severe agoraphobia. GAS was used as a primary outcome measure. Both therapists and independent raters who assessed the level of goal attainment after the intervention, were asked to rate the relevance of the chosen goals on a scale of 1 to 5 (with one meaning irrelevant and five meaning very relevant). Therapists only rated the GAS score of patients not treated by themselves. The mean score of the therapists was 4.68 (SD = .51), and the mean score of the independent raters was 4.66 (SD = .52). The researchers concluded that these numbers show that ‘the goal areas were suitably chosen’. The target population of GAS (the patients) were not involved in this evaluation, which is one of the requirements of the quality criteria that we use. However, it is inherent in the measurement instrument that the patient is involved in the choice of the items. Therefore, we score the quality of the face validity evaluation as ‘good quality’.

Content validity

Content validity was reported in five studies, of which one was a drug study. Content validity was measured in several ways, as shown in Table 5; by rating the usefulness or importance of the goals [21, 22], by comparing the goal areas with essential components as recommended by position papers in the specific field [23] and by checking whether the goals were formulated according to the criteria ‘Specific, Measurable, Assignable, Realistic, and Time-related’(SMART) [24, 25]. In one study, the content validity was reportedly tested by grouping the goals into major categories, and analyzing the content of these categories [26]. However, the study did not report the results of the categorization of the goals [26]. The quality of the content validity varied from ‘good quality’ in two studies, ‘intermediate quality’ in two studies and ‘poor quality’ in one study. Authors reported a ‘good overall usefulness’ of the goals [22], stated that all recommended areas were represented in the goals [23], whether goals were set according to the SMART principle (in this particular study, it was concluded that there was, even after a refinement process of the goal statements, still a difference in the quality of the goal statements between the different sites) [24, 25] or that more than 70 % of the responders rated GAS as a 4 or 5 on a 5-point scale as clinically relevant and important [21].
Table 5

Reported content validity of GAS in included studies

First author

Year

Drug study

N

Methods and results

Quality

Palisano

1993

No

21

10 physical therapists rated 10 randomly selected GAS-goals on a five-point scale on importance (88 % rated a 4 or 5), the expected level of goal attainment (77 % rated 4 or 5) and clinical relevance (79 % rated a 4 or 5). Between 77 and 88 % of the ratings met the criterion.

+

A clear description is provided of the measurement aim, and target population is inherently involved in item selection

Stolee

1999

No

173

Goals were grouped in major categories, of which the most common were mobility, future care, personal care and bowel and bladder problems. The categorization was reviewed by clinicians of the geriatric rehabilitation unit. The results of this review were not mentioned in the article.

-

No results mentioned

Stolee

2012

No

90

Clinicians rated the use of GAS with a mean of 3 (SD 0.9) on a 5-point scale, indicating a “good overall usefulness” of GAS.

+

A clear description is provided of the measurement aim, and target population is inherently involved in item selection

Turner-Stokes

2013

Yes

456

Goal statements for the primary goal in each patient were independently evaluated by three lead clinical investigators, in two rounds. The purpose was to check that clinicians were setting SMART function-related goals in accordance with the training. Goal statements were rated an A, B or C, where an A-rating means ‘Some goal statements contain reference to functional activities at the level of disability or participation—may be ‘active’ or ‘passive’ function’, a B-rating means that ‘Goal statements contain reference to impairment only’, and a C-rating means ‘Goal statements contain reference to anatomical structures only’. Also, a ++, + or – was added, where ++ means ‘There is a SMART goal description, sufficiently detailed and specific to make accurate GAS rating’, + means ‘There is some clear goal description sufficient to support GAS rating, but still reliant on subjective interpretation’ and – means ‘No clear goal \description’. The rating was done in two rounds: after the first round, 62.7 % recorded function-related statements rated A or AB, and 40.3 % of the goal statements received a SMART quality rating of A+/A++. In round two these figures rose to 70.9 and 46.8 % respectively. The authors conclude that even after this goal refinement process, there is residual heterogeneity between the quality of the goals in the different sites that were included in the study.

+

A clear description is provided of the measurement aim, and target population is inherently involved in item selection

Yip

1998

No

143

Content validity was evaluated by comparison of identified goal areas with the essential components of geriatric assessment recommended by several position papers. All the recommended domains were assessed.

+/−

Unclear how and by whom the evaluation was scored

Construct validity

Construct validity was reported in 18 studies, of which six were drug studies (Table 6). In all 18 studies construct validity was assessed by correlations with other instruments measuring a construct similar to the goals that were expected to be set by the patients in each specific research area. Also, T-tests between the placebo and intervention condition [27], or T-tests between the lowest and highest T-score differences [28], were used to verify construct validity. In none of the studies, a hypothesis was formulated on the expected construct validity outcomes. Therefore, the quality of the construct validity is difficult to evaluate. Of the 18 studies, 14 reported significant correlations with other measurement instruments that were relevant for the research area. The measurement instruments used to establish the construct validity varied considerably, since GAS is used for different research areas. Three studies reported that no significant correlations with other measurement instruments were found [21, 29, 30]. In one study correlations between change scores were measured. The results were not clearly reported [31].
Table 6

Reported construct validity of GAS in included studies

First author

Year

Drug study

N

Methods and results

Quality

Cusick

2006

Yes

41

Correlations with COMP and GAS Likert scale were measured; no correlation higher than −0.25 or with a p-value lower than 0.05.

+/−

No hypotheses

De Beurs

1993

Yes

40

Correlations with agoraphobia, rating of treatment outcome by therapist, M-BAT, depression and somatic anxiety were measured; GAS has a high correlation with gain scores on agoraphobia (0.63), rating of treatment outcome by therapist (0.43), and M-BAT (0.57). GAS is moderately correlated with depression (0.32), and not significantly correlated with somatic anxiety.

+/−

No hypotheses

Fisher

2002

No

149

Correlations with improvements in walking, general health questionnaire, Oswesty Low Back Pain Disability Questionnaire, NRS and change stand-sit and change PAIRS were measured. There was a significant correlation between GAS and improvements for walking (0.47), between GAS and the general health questionnaire (0.25) and between GAS and the OLBPDQ (−0.31), with p <0.01 for all three. No significant correlations were found between GAS and the NRS and change stand-sit and change PAIRS.

+/−

No hypotheses

Gordon

1999

No

53

Correlations with standard scales of cognition (MMSE and Global Deterioration Scale), behavior (axis 8 of the brief cognitive rating scale), co-morbidity (cumulative illness rating scale), mobility and balance (hierarchical assessment of balance and mobility, HABAM), and functional capacity (Barthel Index); GAS did not correlate well with any of these measures (correlations varied from −0.22 to 0.17).

+/−

No hypotheses

Khan

2008

No

24

Correlation with Barthel Index, Functional Independent Measure and Clinical Global Impression was measured; only the correlation with CGI was significant (−0.77). Also, the difference between responders and non-responders was measured, and a significant difference was found (Z = −3.78, p <0.001).

+/−

No hypotheses

Palisano

1993

No

21

Correlations between GAS T-scores and Peabody Gross Motor Age equivalent change scores were measured; none of these correlations were significant.

+/−

No hypotheses

Rockwood

1993

No

45

Correlations with change scores of Barthel Index, Functional Independent Measure, Mini-Mental State Examination, Katz ADL Index, Physical Self-Maintenance Scale, and Spitzer Quality of Life Index were measured. Correlations varied from −0.87 to 0.84, but it is unclear if these correlations are significant.

+/−

No hypotheses, correlations between change scores

Rockwood

1996

Yes

15

A correlation with change scores is measured between GAS and Alzheimer’s Disease Assessment Scale-cognitive, Global Deterioration Scale, Clinical Global Impression, Mini-Mental State Examination, Physical Self Maintenance Scale, and the Instrumental Activities of Daily Living. Correlations varied from −0.85 to 0.74, but it is unclear if these correlations are significant. A T-test between the placebo and the intervention condition was also performed. The T-test showed no difference (p = 0.54).

+/−

No hypotheses, correlations between change scores

Rockwood

1997

No

44

Correlations with two measurement instruments were measured: Clinical Global Impression (r = 0.73) for change score and (r = 0.63) at discharge.

+/−

No hypotheses

Rockwood

2002

Yes

108

Correlations were measured between several goals within GAS and other measurement instruments. Mini-Mental State Examination and GAS cognition goals: r = 0.51. Alzheimer’s Disease Assessment Scale-cognitive and GAS cognition goals: r = −0.43. Physical Self Maintenance Scale and clinical function goals: r = −0.53. Patient-carer function goals and Physical Self Maintenance Scale: r = −0.47. Patient-carer function goals and Instrumental Activities of Daily Living: r = −0.44.

+/−

No hypotheses

Sheldon

1998

No

82

GAS was correlated with the ‘rated attainment’ scale: r = 0.71 (p <0.001). There was a correlation with autonomy (r = 0.21, p <0.01), later effort (r = 0.42, p <0.01) and autonomous reasons (r = 0.09, p <0.05).

+/−

No hypotheses

Steenbeek

2011

No

23

Correlation with Pediatric Evaluation of Disability Inventory Functional Status Score Mobility: r = 0.64 (p <0.01), correlation with PEDI Selfcare and social function was not significant.

+/−

No hypotheses

Stolee

1999

No

173

Change and follow-up scores of GAS were correlated with Barthel Index, Older Americans Resource Scale Instrumental Activities of Daily Living, Mini-Mental State Examination, Global Rating, Nottingham Health Profile. The correlations varied from −0.31 to 0.67.

+/−

No hypotheses

Turner-Stokes

2009

No

164

Correlations were measured between GAS and Functional Independent Measure and Functional Assessment Measure. Correlations with FIM + FAM scores were moderate: 0.36–0.43 for raw scores, 0.41–0.49 for GAS transformed FIM + FAM scores.

+/−

No hypotheses

Turner-Stokes

2010

Yes

90

Correlations were measured between GAS and a composite spasticity score (MAS), Global Benefit patient report, Global Benefit investigator report, Hospital Anxiety and Depression Scale anxiety and Hospital Anxiety and Depression Scale depression, Pain at rest, Pain on movement, Assessment of Quality of Life, Patient Disability Score, and Carer burden score. Significant correlations between GAS and MAS (0.35), Global benefit patient report (0.46) and Global benefit investigator-report (0.41) were reported. Other correlations were not significant.

+/−

No hypotheses

Turner-Stokes

2013

Yes

456

Correlations between GAS and ‘other measures of outcome, e.g. measures of spasticity, global benefit and other standardized measures’ were calculated. GAS correlated weakly with a reduction in total Modified Ashworth Scale at follow-up (Sp r = 0.28, p <0.0001) and with global assessment of benefit (r = 0.45, p <0.0001 for patient assessment, r = 0.38, p <0.0001 for investigator assessment).

+/−

No hypotheses

Woodward

1978

No

279

GAS scores correlate significantly with other outcome measures: r = 0.12 - 0.39; p <0.05 (in the paper, it is not clear what these other outcome measures are). There was also a difference between the highest and lowest T-score differences: the highest scorers had a mean pre-post score difference of 42.70 (SD = 6.87), the lowest scorers had a mean pre-post difference of 4.05 (SD = 5.78).

+/−

No hypotheses

Yip

1998

No

143

Correlations with the Standardized Mini-Mental State Examination, the modified Barthel Index, the Katz Index of ADL and the IADL subscale of the Older Americans Resources and Services Questionnaire were used to demonstrate the convergent construct validity of the standardized menu of GAS. Spearman correlations were calculated between GAS summary scores at discharge and change scores on the Barthel, Katz, OARS-IADL, and SMMSE. The correlations of the total GAS score with changes on the three measures of function were statistically significant but modest (r = 0.41 to 0.45); the correlation of GAS with the SMMSE change score was not significant (r = 0.11).

+/−

Modest correlations

Intra- and inter-rater reliability

As can be seen in Tables 3 and 4, intra-rater reliability was not assessed in any of the included studies. Inter-rater reliability was reported in 12 studies, of which two were drug studies. Different methods were used to measure the inter-rater reliability (Table 7). In four studies we rated the quality of the inter-rater reliability as poor, whereas eight studies were rated with ‘good quality’. Eight out of the 12 studies reported an ICC score. Five of those studies reported that the ICC values were all 0.9 and higher [3135]. Two studies reported ICC values between 0.8 and 0.95 [26, 36]. In one study, the reported ICC was lower than 0.5 [37]. The specific calculation for the ICC was reported in one study [37]. Confidence intervals for the ICC values were also reported in one study [35]. Inter-rater reliability was also reported with kappa-values [21, 38], where the values ranged from substantial to almost perfect agreement. Another method that was used was calculating a correlation, which had a value of 0.84 [28]. One study reported ‘agreement’ between objective goal setters and the therapists who performed the interventions, and ‘agreement’ between objective goal setters and people who did the intake of the patients before the patients were randomized. The results were an agreement of 43 and 57 % respectively. However, in the article the method used to calculate this agreement were not reported [20].
Table 7

Reported inter-rater reliability of GAS in included studies

First author

Year

Drug study

N

Methods and results

Quality

Bovend’Eert

2011

No

29

Mixed model ICC(a, k) between therapist and masked assessor scoring procedures is 0.478 (low); LoA −1.52 +/− 24.54.

-

ICC ≤0.7

Brown

1998

No

24

The Pearson’s r correlations and inter-rater ICCs (2,1) between the scores of the treating therapist and the independent raters were r = 0.84 (p <0.0001, n = 360, r2 = 70.90/0) and ICC = 1.00 (between raters: (IF = 1, SS = 0.01; within raters: df = 695, SS = 1, 172.65), respectively. The coefficients between scores of the 2 independent raters were r = 0.81 (p <0.0001, n = 135, rZ = 66.2 %) and ICC = 0.997 (between raters: dl = 1, SS = 1.48; within raters: f = 245, SS = 433,39). The results support acceptable inter-rater reliability of the scores for the goals in this study.

+

ICC ≥0.7

De Beurs

1993

Yes

40

Agreement on the content of the chosen goals was measured between the intakers, in other words the people who performed the first session before the patients were randomized, and therapists was measured. Also, the agreement between the therapists and the people who objectively set the goals, or the goal setters, was measured. Agreement between goal setters and therapists and between goal setters and intakers was 43 and 57 % respectively. The calculations used to establish the agreement were not reported.

-

Unclear design or method, agreement ≤0.7

Palisano

1993

No

21

Before data collection, an inter rater reliability was measured between the author and an examiner (Kappa = 0.89, agreement 90 %). During the study 16 goals were simultaneously scored. The agreement was 88 % (Kappa = 0.75).

+

ICC ≥0.7

Rockwood

1993

No

45

A primary nurse and a multidisciplinary team scored GAS, ICC = 0.91.

+

ICC ≥0.7

Rockwood

1997

No

44

ICC = 0.95 for admission scoring, ICC = 0.95 for discharge scoring, ICC = 0.93 for change score.

+

ICC ≥0.7

Ruble

2012

No

35 + 44 (reference to previous study)

Two raters independently coded 20 % of the GAS forms for the three features of agreement in sample 1 and 2. ICC for average agreement in sample 1 on measurability (0.96, 95 % CI [.87, .99]), difficulty (0.59, 95 % CI [−.18, .81]) and equidistance (0.96, 95 % CI [.74, .99); ICC for average agreement in sample 2 on measurability (1.0), difficulty (0.96, 95 % CI [.83, .99]) and equidistance (0.96, 95 % CI [.84, .99]).

+

Only ICC for difficulty is lower than 0.7

Ruble

2013-a

No

49

Two coders independently coded 39 % of the goals, ICC for social skills = 0.82, ICC for communication skills = 0.86, ICC for learning skills = 0.91.

+

ICC ≥0.7

Ruble

2013-b

No

Not stated (reference to previous study)

Excellent inter-rater reliability was achieved for both study 1 (ICC = 0.99) and study 2 (ICC = 0.90).

+

ICC ≥0.7

Steenbeek

2005

Yes

11

A video scoring and scoring by a physiotherapist were compared, gaining a Kappa of 0.63. 5 out of 33 of the goal scores differed significantly (tested with a Wilcoxon signed rank test).

-

k ≤0.7

Stolee

1999

No

173

ICC (N = 61) = 0.93 of GAS follow-up score. ICC (N = 61) = 0.89 of the separate goals, when checked whether the goals have been attained.

+

ICC ≥0.7

Woodward

1978

No

279

Correlation of two goal attainment scores: 0.84. 33 % scored identical, 78 % within one level, 95 % within two levels. GAS scores did not differ significantly (F(6,268) = 1.25, P >0.10).

-

Non-standard way of measuring inter-rater reliability

Responsiveness

Responsiveness was reported in 14 studies, of which two were drug studies (Table 8). None of the studies used measurement properties as advised by Terwee et al. [19]. Therefore, it is difficult to evaluate the quality of the responsiveness. In nine of those 14 studies, an effect size of the measured differences was reported [26, 2931, 33, 3942]. Of those nine studies, the reported effect size was below 1 in only one study [29]. In five studies, a Relative Efficiency was reported [26, 30, 31, 33, 41]. The relative efficiency of two procedures or measurement instruments is the ratio of their efficiencies. For instance, a comparison can be made between GAS and a regularly used measurement instrument. The Relative Efficiency varied between 3 and 57, but was substantial in most studies, meaning that GAS is more efficient, or needs less observations, than other measurement instruments. A Standardized Response Mean was reported in six studies [22, 23, 26, 4042]. A standardized response mean (SRM) is an effect size index used to measure the responsiveness of scales to clinical change. The SRM is computed by dividing the mean change score by the standard deviation of the change. The SRM’s that were reported varied between 1.2 and 3.54. Two studies measured responsiveness with a paired t-test comparing response before and after the intervention, with a significant difference in GAS T-scores in both studies [22, 39]. In one study, the sensitivity, specificity and positive and negative predictive value were calculated based on a group of responders and non-responders [43]. The results were 52, 85, 81 and 60 %, respectively. In another study, responsiveness was reported as the number of patients who showed a change in T-scores of different goal areas [44]. The proportion of patients showing changes on GAS was larger than on other measurement instruments. The number of patients showing change were nine out of 23 patients on the physical goals, 18 out of 23 patients on occupational goals and 12 out of 18 patients on speech goals, whereas there was only one patient that showed change on the Gross Motor Function Measure (GMFM-66).
Table 8

Reported responsiveness of GAS in included studies

First author

Year

Drug study

N

Methods and results

Quality

Cusick

2006

Yes

41

Ability to detect change overtime, and ability to detect difference in change between groups was measured with regression coefficients and effect sizes. Effect size for the weighted GAS scale: 0.55 (p = 0.036), and for the Likert scale 0,91 (p = 0.003).

+/−

Doubtful design or method

Gordon

1999

No

53

GAS was the most responsive measure, with the highest effect size (1.29) and the highest relative efficiency (53.7).

+/−

Doubtful design or method

Hartman

1997

No

10

Effect size statistic of 2.34; paired t-test before-after of 2.9 (df = 9, p = 0.017).

+/−

Doubtful design or method

Khan

2008

No

24

Effect size 9.0, t = 10.0, Standardized response mean = 2.4

+/−

Doubtful design or method

Palisano

1993

No

21

Of the 84 goals that were formulated for the study, similar information was obtained with the behavioral objective and GAS formats for 33 (39 %) of the goals, and change that could not be measured with the behavioral objective format was measured with the GAS format for 51 (61 %) of the goals. Of the 17 behavioral objectives that were not achieved, the corresponding GAS score documented progress toward the expected outcome (score of - 1) for 2 (12 %) of the goals. Of the 67 behavioral objectives that were achieved, the corresponding GAS score documented progress that exceeded he criteria for achievement of the behavioral objective (score of +1 or +2) for 49 (73 %) of the goals.

+/−

Doubtful design or method

Rockwood

1993

No

45

RE = 4.5; ES = 5.0

+/−

Doubtful design or method

Rockwood

1997

No

44

Relative efficiency: 7.8; Effect size: 5.11

+/−

Doubtful design or method

Rockwood

2003

No

265

GAS was more responsive than other measures for functional improvement in the elderly; Effect size Cohen’s D: 7.8; SRM: 1.2; NRS: 0.58; Relative efficiency: 57.

+/−

Doubtful design or method

Steenbeek

2011

No

23

Individual change score was found in 9/23 (physical), 18/23 (occupational) and 12/18 (speech), and for only one patient a change score was found in the GMFM-66

+/−

Doubtful design or method

Stolee

1999

No

173

GAS ES = 3.52; Standardized response mean = 1.73; Relative efficiency = 3.14

+/−

Doubtful design or method

Stolee

2012

No

90

All three measures of responsiveness indicated that GAS was able to detect meaningful change in this setting: Paired t-test: T(89) = −17.48; p <0.001, SRM = 1.85 (95 % CI 1.50–2.19), ES = 3.27

+/−

Doubtful design or method

Turner-Stokes

2009

No

164

SRM: non-weighed GAS = 2.23, weighed GAS = 2.29. Effect sizes: non-weighed GAS = 3.16, weighed GAS = 3.54

+/−

Doubtful design or method

Turner-Stokes

2010

Yes

90

The group was divided in responders and non-responders, based on the basis of their mean global benefit at the end of the study; across the whole sample, a change in GAS score from baseline of 6 predicted a positive response, with 52 % sensitivity, 85 % specificity, 81 % positive predictive value and 60 % negative predictive value.

+/−

Doubtful design or method

Yip

1998

No

143

Standardized Response Mean was calculated for each instrument, by dividing the mean difference between post-treatment and pre-treatment status by the standard deviation of the mean change score. The SRM was 1.56 for GAS, compared with 0.89, 0.82, 0.72 and 0.54 for the Barthel, Katz, OARS-IADL, and SMMSE, respectively.

+/−

Doubtful design or method

Discussion

In this systematic review, we have found 58 articles, of which 38 drug studies, where GAS was used as an outcome measure. Therefore, we may conclude that GAS has indeed been used in drug studies. Most drug studies that report any information on the validity of GAS, used Botulinum Toxin as an intervention for spasticity, usually in combination with physical or occupational therapy. The generalizability of the results of these validation studies is limited. The validity, responsiveness and reliability of GAS in drug studies have scarcely been studied. In only seven of the 38 drug studies that we found, some validation has been performed. The methods used to validate the measurements instruments often differ from the methods as proposed by COSMIN. The quality of the methods to assess measurement properties varies, and results are often difficult to interpret. We found 20 articles concerning non-drug studies reporting on the validity, responsiveness and inter-rater reliability of GAS. However, also in studies in which GAS was used to evaluate a non-drug intervention, the quality of the validity reports leaves much room for improvement.

In most articles, either drug or non-drug studies, no definition was given of the measurement properties that were assessed, the formulae used for calculation of parameters were not presented, and in some papers the results of the validity check were not reported [26, 31]. Also, none of the included articles describe hypotheses to test construct validity, which makes evaluating the reported results virtually impossible. Therefore, we conclude that the validity and reliability of GAS have not been researched extensively, neither in studies where a drug intervention was evaluated, nor in other studies.

Of all clinimetric characteristics that were investigated, the responsiveness of GAS was investigated most thoroughly. The responsiveness was consistently reported to be very good compared to other measurement instruments, such as the Gross Motor Function Measure (GMFM-66) in the evaluation of children with cerebral palsy, or the Standardized Mini Mental State Examination (SMMSE) for geriatric assessment. However, none of the studies evaluated the responsiveness according to the guidelines as proposed by Terwee et al. [19]. Therefore, it is difficult to be conclusive on the responsiveness of GAS, although the reported results suggest we may tentatively be optimistic.

The search of this systematic review was very sensitive, to make sure that no studies on GAS were missed. However, our definition of GAS is rather specific, which excludes studies with an approach that is similar, but not exactly the same. Also, we may have missed studies that did not use similar terminology, but did use an approach similar to GAS.

Our findings are consistent with previous systematic reviews on the measurement properties of GAS. For instance, Steenbeek et al. [10] concluded that, in the setting of pediatric rehabilitation, GAS is a very responsive method for treatment evaluation and individual goal setting, but sufficient knowledge is lacking about its reliability and validity, particularly. Also, in the field of psychogeriatrics, GAS may be considered useful from a theoretical point of view. Geriatric patients are heterogeneous, and GAS may be a useful tool to evaluate geriatric interventions. However, the measurement properties of GAS in geriatrics show mixed results. The evidence is not yet strong enough to state that GAS is an applicable outcome measure in this particular field [14]. In a systematic review on the feasibility of measurement instruments related to goal setting, GAS is considered a helpful tool for setting goals, although it is time-consuming and may be difficult for patients with cognitive impairments. However, the patient-centered nature of GAS makes it easier to focus on meaningful patient-directed treatment goals. Also, according to the results the scaling of GAS makes it possible to detect very small progress that may be of great significance to the patient, underlining its potential in responsiveness [45].

A problem in the evaluation of the validity of GAS may be that GAS does not measure one clear construct, since the content of the goals generally differs from patient to patient. One of the possibilities to overcome this inherent problem may be to make an item bank of possible goals that patients would be able to choose from, to make sure that the methodological properties of the goals are known [46]. However, this would be practically very difficult to achieve, since we suspect that for many orphan diseases the patient numbers are smaller, and goals could be more diverse than those of non-orphan disease patients. Another way of approaching the construct validity is to see GAS as a measurement instrument that measures the construct of the attainment of goals. Then, the construct validity could be evaluated by comparing GAS with another measurement instrument that evaluates the attainment of goals, such as the COPM. To our knowledge, this approach has not been considered so far.

The importance and difficulty of goals are often taken into account by assigning weights to the goals (more important goals are assigned a larger weight then less important goals). However, terms such as importance and difficulty are by nature subjective. What is important for one patient, may be less important for another. For example, a Duchenne patient may perceive being able to brush his teeth as very important, where someone else may conceive it as trivial. Can this difference in importance objectively be measured? In a study on the reliability of GAS weights, Marson, Wei and Wasserman [47] conclude that assigning weights to the goals of GAS according to the severity of the problem has an acceptable inter-rater reliability when scored by different objective students trained in the use of GAS. This indicates that although importance and difficulty are difficult to objectively measure, objective raters may still score goals similarly. However, more research should be carried out on this topic to answer the question more definitively.

GAS is a measurement instrument with a high potential, especially in rare diseases, but in order to use it in drug studies, more research on its validity is essential. One way of achieving this would be to use GAS as an additional measurement instrument in an ongoing drug trial, to further explore its validity. For GAS to be possibly useful, the effect of the evaluated drug should be objectively measureable in terms of behavior, and it should measure something that is valuable and noticeable for a patient, and cannot be measured otherwise. Also, the drug that is evaluated should have an effect that is also clinically relevant. Again, Duchenne Muscular Dystrophy may serve as an example. A potential drug should do more than just improve for instance the dystrophin values in muscle biopsies. It should be able to improve something that is valuable for the patient, which can be measured by activities that patients perceive as important, such as brushing teeth or using a computer. GAS may be a useful outcome measure, since it can evaluate a potential drug on a patient level, and is therefore intrinsically clinically relevant.

According to guidelines on Patient Reported Outcomes and Health Related Quality of Life by the FDA and EMA, and open comments on these guidelines by experts [48], the following qualities were essential: a PRO should be based on a clearly defined framework, patients should be involved in the development of the measurement instrument, PRO claims should be based on and supported by improvement in all domains of a specific disease, an appropriate recall period is necessary when the effects of an intervention are tested, the test-retest reliability should be assessed, as well as the ability to detect change and the interpretability of the measurement instrument. Finally, an effect found by a PRO measurement instrument can only be valid when found in an RCT.

In general these requirements also apply to GAS, e.g. patient involvement. However, not all of them are applicable to this instrument, such as test-retest reliability. Before GAS can be used in drug trials, more validity research is needed. GAS has not yet been sufficiently validated to be supported by the regulatory agencies, but it may have potential in specific drug trials, especially in rare diseases where there is a lack of validated and responsive outcome measurement instruments.

Conclusion

We conclude that currently there is insufficient information to assess the validity of GAS, due to the poor quality of the validity studies. However, the overall reported good responsiveness of GAS suggests that it may be a valuable measurement instrument. GAS is an outcome measure that is inherently relevant for patients, making it a valuable tool for research in heterogeneous and small samples. Therefore, we think that GAS needs further validation in drug studies, especially since GAS can be a potential solution when only a small heterogeneous patient group is available to test a promising new drug.

Abbreviations

ADAS-cog, Alzheimer’s disease assessment scale – cognitive subscale; AHA, assisting hand assessment; AMPS, assessment of motor and process scales; AQoL, assessment of quality of life; ARAT, action research arm test; AUC, Area under the receiver operating characteristics curve; BAD-scale, Barry-Albright Dystonia scale; CBS, Caregiving Burden Scale; CDS, Cardiac depression scale; CES-D, Center for epidemiological studies depression scale; CGI, clinical global impression; CHQ, child heath questionnaire; CIBIC-plus, Clinician’s interview based impression of change-plus; COPM, Canadian occupational performance measure; DAD, disability assessment for dementia; DCD Pinch, dynamic computerized dynamometry; FAC, functional ambulation category; FAQ, functional activities questionnaire; FIM, functional independence measure; GAS, goal attainment scaling; GHQ, general health questionnaire; GMFM, gross motor function measure; HADS, hospital anxiety and depression scale; IADL, instrumental activities of daily living; ICC, intraclass correlation coefficient; LASIS, leeds adult spasticity impact scale; LoA, limits of agreement; MAS, modified Ashworth scale; MAUULF, Melbourne assessment of unilateral upper limb function; MHOQ, Michigan hand outcomes questionnaire; MIC, minimal important change; MMSE, mini-mental state examination; MPQ, McGill pain questionnaire; MTS, Modified Tardieu Scale; NHP, Nottingham health profile; NRS, pain intensity numerical rating scale; OARS IADL, Older Americans resource scale for instrumental activities of daily living; ODQ, Oswestry low back pain disability questionnaire; PAIRS, pain and impairment relationship scale; PDMS-FM, peabody developmental motor scale – fine motor; PEDI, pediatric evaluation of disability inventory; PET-GAS, psychometrically equivalence tested goal attainment scaling; PSMS, physical self-maintenance scale; QoL, quality of life; QUEST, quality of upper extremity skills test; RR, responsiveness ratio; SDC, smallest detectable change; TSA, Tardieu Spasticity Angle

Declarations

Acknowledgements

We would like to thank René Spijker for his excellent help with the design of the literature search.

Funding

This research was funded by the EU FP7 program: EU FP7 HEALTH.2013.4.2-3 project Advances in Small Trials dEsign for Regulatory Innovation and eXcellence (Asterix): Grant 603160.

Availability of data and materials

The dataset supporting the conclusions of this article is included within the article and its additional files.

Authors’ contributions

CMWG has set up and executed the study, and written the article. MCJ has co-written the article, was second reviewer in the abstract selection process and second reviewer in the data-extraction process, and has helped with the analysis and interpretation. SSW has co-written the article, was second reviewer in the abstract selection process and has helped with the analysis and interpretation. JHL has co-written the article, was second reviewer in the abstract selection process and second reviewer in the data-extraction process, and has designed and supervised the study. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable, as this study concerns literature only.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Pediatric clinical Research Office, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
(2)
Department of Clinical Genetics and EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands

References

  1. McDonald CM, Henricson EK, Abresch RT, Florence J, Eagle M, Gappmaier E, et al. The 6-minute walk test and other clinical endpoints in duchenne muscular dystrophy: reliability, concurrent validity, and minimal clinically important differences from a multicenter study. Muscle Nerve. 2013;48(3):357–68. doi:10.1002/mus.23905.View ArticlePubMedPubMed CentralGoogle Scholar
  2. McDonald CM, Henricson EK, Han JJ, Abresch RT, Nicorici A, Elfring GL, et al. The 6-minute walk test as a new outcome measure in Duchenne muscular dystrophy. Muscle Nerve. 2010;41(4):500–10. doi:10.1002/mus.21544.View ArticlePubMedGoogle Scholar
  3. Mayhew A, Mazzone ES, Eagle M, Duong T, Ash M, Decostre V, et al. Development of the performance of the upper limb module for Duchenne muscular dystrophy. Dev Med Child Neurol. 2013;55(11):1038–45.View ArticlePubMedGoogle Scholar
  4. De Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine: a practical guide. Cambridge: Cambridge University Press; 2011.View ArticleGoogle Scholar
  5. Mendell JR, Csimma C, McDonald CM, Escolar DM, Janis S, Porter JD, et al. Challenges in drug development for muscle disease: a stakeholders’ meeting. Muscle Nerve. 2007;35(1):8–16.View ArticlePubMedGoogle Scholar
  6. Kiresuk TJ, Sherman RE. Goal attainment scaling: a general method for evaluating comprehensive community mental health programs. Community Ment Health J. 1968;4(6):443–53. doi:10.1007/bf01530764.View ArticlePubMedGoogle Scholar
  7. Kiresuk TJ, Smith A, Cardillo JE. Goal attainment scaling: applications, theory, and measurement. London: Psychology Press; 2014.Google Scholar
  8. Odding E, Roebroeck ME, Stam HJ. The epidemiology of cerebral palsy: incidence, impairments and risk factors. Disabil Rehabil. 2006;28(4):183–91. doi:10.1080/09638280500158422.View ArticlePubMedGoogle Scholar
  9. Pandyan AD, Gregoric M, Barnes MP, Wood D, Van Wijck F, Burridge J, et al. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil. 2005;27(1–2):2–6.View ArticlePubMedGoogle Scholar
  10. Steenbeek D, Ketelaar M, Galama K, Gorter JW. Goal attainment scaling in paediatric rehabilitation: a critical review of the literature. Dev Med Child Neurol. 2007;49(7):550–6. doi:10.1111/j.1469-8749.2007.00550.x.View ArticlePubMedGoogle Scholar
  11. van Kuijk AA, Geurts AC, Bevaart BJ, van Limbeek J. Treatment of upper extremity spasticity in stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the literature. J Rehabil Med. 2002;34(2):51–61.View ArticlePubMedGoogle Scholar
  12. Wade DT. Goal planning in stroke rehabilitation: evidence. Topology. 1999;6(2):37–42. http://dx.doi.org/10.1310/FMYJ-RKG1-YANB-WXRH.Google Scholar
  13. Birks J, Craig D. Galantamine for vascular cognitive impairment. Cochrane Database Syst Rev. 2013;4:Cd004746. doi:10.1002/14651858.CD004746.pub2.Google Scholar
  14. Bouwens SF, van Heugten CM, Verhey FR. Review of goal attainment scaling as a useful outcome measure in psychogeriatric patients with cognitive disorders. Dement Geriatr Cogn Disord. 2008;26(6):528–40. doi:10.1159/000178757.View ArticlePubMedGoogle Scholar
  15. Loy C, Schneider L. Galantamine for Alzheimer’s disease and mild cognitive impairment. Cochrane Database Syst Rev. 2006;1:Cd001747. doi:10.1002/14651858.CD001747.pub3.Google Scholar
  16. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res. 2010;19(4):539–49.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.View ArticlePubMedGoogle Scholar
  18. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes. J Clin Epidemiol. 2010;63(7):737–45.View ArticlePubMedGoogle Scholar
  19. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34–42.View ArticlePubMedGoogle Scholar
  20. De Beurs E, Lange A, Blonk RWB, Koele P, Van Balkom AJLM, Van Dyck R. Goal attainment scaling: an idiosyncratic method to assess treatment effectiveness in agoraphobia. J Psychopathol Behav Assess. 1993;15(4):357–73.View ArticleGoogle Scholar
  21. Palisano RJ, Gowland C. Validity of goal attainment scaling in infants with motor delays. Phys Ther. 1993;73(10):651–60.PubMedGoogle Scholar
  22. Stolee P, Awad M, Byrne K, DeForge R, Clements S, Glenny C. A multi-site study of the feasibility and clinical utility of Goal Attainment Scaling in geriatric day hospitals. Disabil Rehabil. 2012;34(20):1716–26. http://dx.doi.org/10.3109/09638288.2012.660600.View ArticlePubMedGoogle Scholar
  23. Yip AM, Gorman MC, Stadnyk K, Mills WG, MacPherson KM, Rockwood K. A standardized menu for Goal Attainment Scaling in the care of frail elders. Gerontologist. 1998;38(6):735–42.View ArticlePubMedGoogle Scholar
  24. Turner-Stokes L, Fheodoroff K, Jacinto J, Maisonobe P. Results from the Upper Limb International Spasticity Study-II (ULIS-II): a large, international, prospective cohort study investigating practice and goal attainment following treatment with botulinum toxin a in real-life clinical management. BMJ Open. 2013;3(6). http://dx.doi.org/10.1136/bmjopen-2013-002771.
  25. Turner-Stokes L, Fheodoroff K, Jacinto J, Maisonobe P, Zakine B. Upper limb international spasticity study: rationale and protocol for a large, international, multicentre prospective cohort study investigating management and goal attainment following treatment with botulinum toxin A in real-life clinical practice. BMJ Open. 2013;3(3). http://dx.doi.org/10.1136/bmjopen-2012-002230.
  26. Stolee P, Stadnyk K, Myers AM, Rockwood K. An individualized approach to outcome measurement in geriatric rehabilitation. J Gerontol Ser A Biol Med Sci. 1999;54A(12):M641–M7. http://dx.doi.org/10.1093/gerona/54.12.M641.View ArticleGoogle Scholar
  27. Rockwood K, Stolee P, Howard K, Mallery L. Use of Goal Attainment Scaling to measure treatment effects in an anti-dementia drug trial. Neuroepidemiology. 1996;15(6):330–8.View ArticlePubMedGoogle Scholar
  28. Woodward CA, Santa-Barbara J, Levin S, Epstein NB. The role of goal attainment scaling in evaluating family therapy outcome. Am J Orthopsychiatry. 1978;48(3):464–76.View ArticlePubMedGoogle Scholar
  29. Cusick A, McIntyre S, Novak I, Lannin N, Lowe K. A comparison of goal attainment scaling and the Canadian Occupational Performance Measure for paediatric rehabilitation research. Pediatr Rehabil. 2006;9(2):149–57.View ArticlePubMedGoogle Scholar
  30. Gordon JE, Powell C, Rockwood K. Goal attainment scaling as a measure of clinically important change in nursing-home patients. Age Ageing. 1999;28(3):275–81.View ArticlePubMedGoogle Scholar
  31. Rockwood K, Stolee P, Fox RA. Use of goal attainment scaling in measuring clinically important change in the frail elderly. J Clin Epidemiol. 1993;46(10):1113–8.View ArticlePubMedGoogle Scholar
  32. Brown DA, Effgen SK, Palisano RJ. Performance following ability-focused physical therapy intervention in individuals with severely limited physical and cognitive abilities. Phys Ther. 1998;78(9):934–47. discussion 48–50.PubMedGoogle Scholar
  33. Rockwood K, Joyce B, Stolee P. Use of goal attainment scaling in measuring clinically important change in cognitive rehabilitation patients. J Clin Epidemiol. 1997;50(5):581–8.View ArticlePubMedGoogle Scholar
  34. Ruble L, McGrew JH. Teacher and child predictors of achieving IEP goals of children with autism. J Autism Dev Disord. 2013;43(12):2748–63. http://dx.doi.org/10.1007/s10803-013-1884-x.View ArticlePubMedGoogle Scholar
  35. Ruble L, McGrew JH, Toland MD. Goal attainment scaling as an outcome measure in randomized controlled trials of psychosocial interventions in autism. J Autism Dev Disord. 2012;42(9):1974–83. http://dx.doi.org/10.1007/s10803-012-1446-7.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Ruble LA, McGrew JH, Toland MD, Dalrymple NJ, Jung LA. A randomized controlled trial of COMPASS web-based and face-to-face teacher coaching in autism. J Consult Clin Psychol. 2013;81(3):566–72. http://dx.doi.org/10.1037/a0032003.View ArticlePubMedPubMed CentralGoogle Scholar
  37. Bovend’Eerdt TJ, Dawes H, Izadi H, Wade DT. Agreement between two different scoring procedures for goal attainment scaling is low. J Rehabil Med. 2011;43(1):46–9. http://dx.doi.org/10.2340/16501977-0624.View ArticlePubMedGoogle Scholar
  38. Steenbeek D, Meester-Delver A, Becher JG, Lankhorst GJ. The effect of botulinum toxin type a treatment of the lower extremity on the level of functional abilities in children with cerebral palsy: evaluation with goal attainment scaling. Clin Rehabil. 2005;19(3):274–82.View ArticlePubMedGoogle Scholar
  39. Hartman D, Borrie MJ, Davison E, Stolee P. Use of goal attainment scaling in a dementia special care unit. Am J Alzheimers Dis. 1997;12(3):111–6. http://dx.doi.org/10.1177/153331759701200303.View ArticleGoogle Scholar
  40. Khan F, Pallant JF, Turner-Stokes L. Use of goal attainment scaling in inpatient rehabilitation for persons with multiple sclerosis. Arch Phys Med Rehabil. 2008;89(4):652–9. http://dx.doi.org/10.1016/j.apmr.2007.09.049.View ArticlePubMedGoogle Scholar
  41. Rockwood K, Howlett S, Stadnyk K, Carver D, Powell C, Stolee P. Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment. J Clin Epidemiol. 2003;56(8):736–43.View ArticlePubMedGoogle Scholar
  42. Turner-Stokes L, Williams H, Johnson J. Goal attainment scaling: does it provide added value as a person-centred measure for evaluation of outcome in neurorehabilitation following acquired brain injury? J Rehabil Med. 2009;41(7):528–35. http://dx.doi.org/10.2340/16501977-0383.View ArticlePubMedGoogle Scholar
  43. Turner-Stokes L, Baguley IJ, De Graaff S, Katrak P, Davies L, McCrory P, et al. Goal attainment scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial. J Rehabil Med. 2010;42(1):81–9. http://dx.doi.org/10.2340/16501977-0474.View ArticlePubMedGoogle Scholar
  44. Steenbeek D, Gorter JW, Ketelaar M, Galama K, Lindeman E. Responsiveness of Goal Attainment Scaling in comparison to two standardized measures in outcome evaluation of children with cerebral palsy. Clin Rehabil. 2011;25(12):1128–39. http://dx.doi.org/10.1177/0269215511407220.View ArticlePubMedGoogle Scholar
  45. Stevens A, Beurskens A, Köke A, van der Weijden T. The use of patient-specific measurement instruments in the process of goal-setting: a systematic review of available instruments and their feasibility. Clin Rehabil. 2013;0269215513490178.Google Scholar
  46. Tennant A. Goal attainment scaling: current methodological challenges. Disabil Rehabil. 2007;29(20–21):1583–8.View ArticlePubMedGoogle Scholar
  47. Marson SM, Wei G, Wasserman D. A reliability analysis of goal attainment scaling (GAS) weights. Am J Eval. 2009;30(2):203–16.View ArticleGoogle Scholar
  48. Bottomley A, Jones D, Claassens L. Patient-reported outcomes: assessment and current perspectives of the guidelines of the food and drug administration and the reflection paper of the European medicines agency. Eur J Cancer. 2009;45(3):347–53.View ArticlePubMedGoogle Scholar
  49. Mokkink L, Terwee C, Patrick D, Alonso J, Strat-ford P, Knol D, et al. International consensus on taxonomy, terminology, and definitionsof measurement properties for health-related patientreportedoutcomes: results of the COSMIN study. J Clin Epidemiol.Google Scholar
  50. Rockwood K, Graham JE, Fay S, Investigators A. Goal setting and attainment in Alzheimer's disease patients treated with donepezil. J Neurol Neurosurg Psychiatry. 2002;73(5):500–7.View ArticlePubMedPubMed CentralGoogle Scholar
  51. Ashford S, Turner-Stokes L. Ma of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions: a preliminary analysis of goals and outcomes. Disabil Rehabil. 2009;31(3):220–6. http://dx.doi.org/10.1080/09638280801906388.View ArticlePubMedGoogle Scholar
  52. Barden HL, Baguley IJ, Nott MT, Chapparo C. Dynamic computerised hand dynamometry: Measuring outcomes following upper limb botulinum toxin-A injections in adults with acquired brain injury. J Rehabil Med. 2014;46(4):314–20.View ArticlePubMedGoogle Scholar
  53. Barden HLH, Baguley IJ, Nott MT, Chapparo C. Measuring spasticity and fine motor control (pinch) change in the hand after botulinum toxin-a injection using dynamic computerized hand dynamometry. Arch Phys Med Rehabil. 2014;95(12):2402–9.View ArticlePubMedGoogle Scholar
  54. Bonouvrie LA, Becher JG, Vles JSH, Boeschoten K, Soudant D, de Groot V, et al. Intrathecal baclofen treatment in dystonic cerebral palsy: a randomized clinical trial: The IDYS trial. BMC Pediatr. 2013;13(1). http://dx.doi.org/10.1186/1471-2431-13-175.
  55. Borg J, Ward AB, Wissel J, Kulkarni J, Sakel M, Ertzgaard P, et al. Rationale and design of a multicentre, double-blind, prospective, randomized, European and Canadian study: evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity. J Rehabil Med. 2011;43(1):15–22. http://dx.doi.org/10.2340/16501977-0663.View ArticlePubMedGoogle Scholar
  56. Demetrios M, Gorelik A, Louie J, Brand C, Baguley IJ, Khan F. Outcomes of ambulatory rehabilitation programmes following Botulinum toxin for spasticity in adults with stroke. J Rehabil Med. 2014;46(8):730–7.View ArticlePubMedGoogle Scholar
  57. Ferrari A, Maoret AR, Muzzini S, Alboresi S, Lombardi F, Sgandurra G, et al. A randomized trial of upper limb botulimun toxin versus placebo injection, combined with physiotherapy, in children with hemiplegia. Res Dev Disabil. 2014;35(10):2505–13.View ArticlePubMedGoogle Scholar
  58. Fietzek UM, Schroeteler FE, Ceballos-Baumann AO. Goal attainment after treatment of parkinsonian camptocormia with botulinum toxin. Mov Disord. 2009;24(13):2027–8. http://dx.doi.org/10.1002/mds.22676.View ArticlePubMedGoogle Scholar
  59. Lam K, Lau KK, So KK, Tam CK, Wu YM, Cheung G, et al. Can botulinum toxin decrease carer burden in long term care residents with upper limb spasticity? A randomized controlled study. J Am Med Dir Assoc. 2012;13(5):477–84. http://dx.doi.org/10.1016/j.jamda.2012.03.005.View ArticlePubMedGoogle Scholar
  60. Lam K, Wong D, Tam CK, Wah SH, Myint MWWJ, Yu TKK, et al. Ultrasound and electrical stimulator-guided obturator nerve block with phenol in the treatment of Hip adductor spasticity in long-term care patients: a randomized, triple blind, placebo controlled study. J Am Med Dir Assoc. 2015;16(3):238–46.View ArticlePubMedGoogle Scholar
  61. Leroi I, Atkinson R, Overshott R. Memantine improves goal attainment and reduces caregiver burden in Parkinson's disease with dementia. Int J Geriatr Psychiatry. 2014;29(9):899–905.View ArticlePubMedGoogle Scholar
  62. Lowe K, Novak I, Cusick A. Low-dose/high-concentration localized botulinum toxin A improves upper limb movement and function in children with hemiplegic cerebral palsy. Dev Med Child Neurol. 2006;48(3):170–5.View ArticlePubMedGoogle Scholar
  63. Lowe K, Novak I, Cusick A. Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with cerebral palsy. Dev Med Child Neurol. 2007;49(11):823–9.View ArticlePubMedGoogle Scholar
  64. Mall V, Heinen F, Siebel A, Bertram C, Hafkemeyer U, Wissel J, et al. Treatment of adductor spasticity with BTX-A in children with CP: a randomized, double-blind, placebo-controlled study. Dev Med Child Neurol. 2006;48(1):10–3.View ArticlePubMedGoogle Scholar
  65. McCrory P, Turner-Stokes L, Baguley IJ, De Graaff S, Katrak P, Sandanam J, et al. Botulinum toxin A for treatment of upper limb spasticity following stroke: a multi-centre randomized placebo-controlled study of the effects on quality of life and other person-centred outcomes. J Rehabil Med. 2009;41(7):536–44. http://dx.doi.org/10.2340/16501977-0366.View ArticlePubMedGoogle Scholar
  66. Molenaers G, Fagard K, Van Campenhout A, Desloovere K. Botulinum toxin A treatment of the lower extremities in children with cerebral palsy. J Child Orthop. 2013;7(5):383–7.View ArticlePubMedPubMed CentralGoogle Scholar
  67. Nott MT, Barden HL, Baguley IJ. Goal attainment following upper-limb botulinum toxin-A injections: Are we facilitating achievement of client-centred goals? J Rehabil Med. 2014;46(9):864–8.View ArticlePubMedGoogle Scholar
  68. Olesch CA, Greaves S, Imms C, Reid SM, Graham HK. Repeat botulinum toxin-A injections in the upper limb of children with hemiplegia: a randomized controlled trial. Dev Med Child Neurol. 2010;52(1):79–86. http://dx.doi.org/10.1111/j.1469-8749.2009.03387.x.View ArticlePubMedGoogle Scholar
  69. Rice J, Waugh MC. Pilot study on trihexyphenidyl in the treatment of dystonia in children with cerebral palsy. J Child Neurol. 2009;24(2):176–82. http://dx.doi.org/10.1177/0883073808322668.View ArticlePubMedGoogle Scholar
  70. Rockwood K, Fay S, Song X, MacKnight C, Gorman M. Video-imaging synthesis of treating Alzheimer's disease I. Attainment of treatment goals by people with Alzheimer's disease receiving galantamine: a randomized controlled trial. Cmaj. 2006;174(8):1099–105.View ArticlePubMedPubMed CentralGoogle Scholar
  71. Rockwood K, Fay S, Jarrett P, Asp E. Effect of galantamine on verbal repetition in AD: a secondary analysis of the VISTA trial. Neurology. 2007;68(14):1116–21.View ArticlePubMedGoogle Scholar
  72. Rockwood K, Fay S, Gorman M, Carver D, Graham JE. The clinical meaningfulness of ADAS-Cog changes in Alzheimer's disease patients treated with donepezil in an open-label trial. BMC Neurol. 2007;7:26.View ArticlePubMedPubMed CentralGoogle Scholar
  73. Rockwood K, Fay S, Gorman M. The ADAS-cog and clinically meaningful change in the VISTA clinical trial of galantamine for Alzheimer's disease. Int J Geriatr Psychiatry. 2010;25(2):191–201. http://dx.doi.org/10.1002/gps.2319.View ArticlePubMedGoogle Scholar
  74. Russo RN, Crotty M, Miller MD, Murchland S, Flett P, Haan E. Upper-limb botulinum toxin A injection and occupational therapy in children with hemiplegic cerebral palsy identified from a population register: a single-blind, randomized, controlled trial. Pediatrics. 2007;119(5):e1149–58.View ArticlePubMedGoogle Scholar
  75. Scheinberg A, Hall K, Lam LT, O'Flaherty S. Oral baclofen in children with cerebral palsy: a double-blind crossover pilot study. J Paediatr Child Health. 2006;42(11):715–20.View ArticlePubMedGoogle Scholar
  76. Schramm A, Ndayisaba J-P, Brinke M, Hecht M, Herrmann C, Huber M et al. Spasticity treatment with onabotulinumtoxin a: Data from a prospective german real-life patient registry. J Neural Transm. 2014(Pagination):No Pagination Specified. http://dx.doi.org/10.1007/s00702-013-1145-3.
  77. Turner-Stokes L, Ashford S. Serial injection of botulinum toxin for muscle imbalance due to regional spasticity in the upper limb. Disabil Rehabil. 2007;29(23):1806–12.View ArticlePubMedGoogle Scholar
  78. Wallen MA, O'Flaherty SJ, Waugh MCA. Functional Outcomes of Intramuscular Botulinum Toxin Type A in the Upper Limbs of Children with Cerebral Palsy: A Phase II Trial. Arch Phys Med Rehabil. 2004;85(2):192–200. http://dx.doi.org/10.1016/j.apmr.2003.05.008.View ArticlePubMedGoogle Scholar
  79. Wallen M, O'Flaherty SJ, Waugh MC. Functional outcomes of intramuscular botulinum toxin type a and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(1):1–10.View ArticlePubMedGoogle Scholar
  80. Ward FA, Pulido-Velazquez M. Incentive pricing and cost recovery at the basin scale. J environ manage. 2009;90(1):293–313. http://dx.doi.org/10.1016/j.jenvman.2007.09.009.View ArticlePubMedGoogle Scholar
  81. Ward AB, Wissel J, Borg J, Ertzgaard P, Herrmann C, Kulkarni J, et al. Functional goal achievement in poststroke spasticity patients: The BOTOX® Economic Spasticity Trial (BEST). J Rehabil Med. 2014;46(6):504–13.View ArticlePubMedGoogle Scholar
  82. Bovend'Eerdt TJ, Dawes H, Sackley C, Izadi H, Wade DT. An integrated motor imagery program to improve functional task performance in neurorehabilitation: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2010;91(6):939–46.View ArticlePubMedGoogle Scholar
  83. Fisher K, Hardie RJ. Goal attainment scaling in evaluating a multidisciplinary pain management programme. Clin Rehabil. 2002;16(8):871–7.View ArticlePubMedGoogle Scholar
  84. Sheldon KM, Elliot AJ. Not all personal goals are personal: Comparing autonomous and controlled reasons for goals as predictors of effort and attainment. Personal Soc Psychol Bull. 1998;24(5):546–57. http://dx.doi.org/10.1177/0146167298245010.View ArticleGoogle Scholar

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