Can goal setting be isolated from activity‐focused intervention in cerebral palsy?

Abstract

SIR–The systematic review by Carlberg and L€ owing was particularly thought-provoking and addressed a critical and contemporary issue in paediatric rehabilitation. We would like to offer some perspectives on this publication. The aim of the review was to identify if the process of goal setting could influence treatment outcome of activity-focused interventions measured by standardized assessment. The authors reported that ‘. . . none of the studies was designed specifically to determine the effect of goal setting per se,’ and it was ‘. . . difficult to separate the effect of the goal setting from the effect of intervention . . .’ as goal setting was integral to guiding the activity-focused interventions being examined. Intuitively, it is plausible that involving families in goal setting focuses attention on priority activities and may influence parents to engage with their child to focus on mastery of goals. Important and clinically useful information would result from understanding whether goal setting influences treatment outcome. As the authors didn’t find studies evaluating the effects of goal setting per se, they recommended that studies are needed which ‘. . . specifically assess the effect of goal setting on treatment outcome . . .’ Two options are possible when contemplating the highest level of evidence that would isolate goal setting as an intervention. In the first, participants would be randomized to a group participating in goal setting and no intervention, or a comparison group receiving no intervention. This option is unlikely to be palatable to participants, researchers, or ethics bodies. In the other option, participants could be randomized to goal setting and activityfocused intervention or activity-focused intervention alone to isolate goal setting as the independent variable. Activityfocused intervention, however, is reliant on goal setting to direct and focus the nature and course of intervention. Consequently, neither option is feasible, which illustrates why Carlberg and L€ owing did not locate studies evaluating goal setting per se. Another more feasible option exists, albeit providing lower level evidence. Randomized controlled trials (RCTs) with a non-treatment control group, where outcome measurement included goal attainment, would provide information of the effects of goal setting. Failure of such control groups to achieve a meaningful treatment effect in the presence of a significant between-group difference would provide evidence that goal setting alone may not influence outcomes. If, on the other hand, the control group achieved clinically meaningful outcomes, evidence may exist in support of goal setting alone influencing outcomes. Two RCTs illustrate this option, both of which were included in Carlberg and L€ owing’s review. Wallen et al.’s four-group RCT evaluated the effects of botulinum toxin-A injections, with and without occupational therapy, to the upper limbs of children with cerebral palsy. The no-treatment group failed to reach average goal achievement using Goal Attainment Scaling (GAS) at either 3or 6-month endpoints. The control group in Novak et al.’s study of home programme implementation failed to achieve any change on the GAS over the course of the study. Results from these studies suggest goal setting alone may not be sufficient to effect meaningful change. Carlberg and L€ owing concluded that their review did not ‘. . . provide support for a positive effect of goal setting . . .’ These words are reminiscent of Braithwaite’s six dangerous words in evidence-based medicine: ‘There is no evidence to suggest . . .’ The conclusion that the review failed to find support for a positive effect of goal setting could mean that the evidence reviewed was inconclusive or that the evidence suggested that goal setting did not affect outcome. The conclusion reported by Carlberg and L€ owing is not strictly incorrect but it is ambiguous and potentially, though unintentionally, misleading. Rather than failing to find support for goal setting, Carlberg and L€ owing didn’t actually find a study which addressed the review question. Alternatively, accurately reporting that they did not locate any studies which addressed the review question would have been precise, unambiguous, and clearly identified the status of available evidence. Such a conclusion provokes consideration of the intricacies of conducting research that would isolate goal setting as the independent variable in studies of activity-focused intervention. Goal setting is inherently intertwined with many current and evidence-based, activity-focused interventions for children with cerebral palsy.