Goal Setting for Pain Rehabilitation

“Goal Setting for Pain Rehabilitation” is part of a series of six Whole Health tools designed to assist clinicians who want to enhance Veteran’s chronic pain self-management skills.  For additional information, see also the other materials in “Self-Management of Chronic Pain.”

Instructions for Clinicians

The importance of goal setting

It is very common for people with chronic pain to feel overwhelmed and isolated because of their condition.  They often use ineffective coping patterns and decrease their activity levels.  They may become preoccupied with the single goal of decreasing their pain, spending a lot of time and resources trying to do so.  Having pain reduction as a solitary goal puts people at risk for frustration, depression, and decreased participation in care.[1]  It is important to help patients recognize that pain may or may not improve, but their level of functioning and management of their condition most definitely can.

Chronic pain requires day-to-day management by each person affected by it, and clinicians are in a unique position to educate and prescribe self-management approaches for them.  Some approaches include having patients set functional goals and encouraging them to work on improving their quality of their life despite their pain.

Goal setting approaches have been shown to increase patients’ progress toward mutually agreed upon goals and to foster adherence to physicians’ recommendations.[2][3]  Goal setting helps create a successful individualized pain rehabilitation plan[2][3] and improves physician-patient communication.[4]

Time is limited during visits, but it is important to make goal setting with chronic pain patients a priority.  Collaboratively setting goals with patients’ input leads to higher compliance than provider-mandated goals.[5] A clear, agreed upon treatment plan with concrete tasks to accomplish between appointments will assist the patient in moving forward.  Goal setting is a tool that encourages patient accountability, fosters their self-efficacy through development of active coping strategies, and allows them to gain some control over their condition.  It allows clinicians to monitor the patient’s progress and determine whether continued treatment is warranted.  Goal setting also provides opportunities for clinician feedback on goal completion and such feedback reinforces future goal setting.[6]

How to set goals with patients

By teaching patients a process for setting goals, clinicians can help them achieve small successes that they can use to rebuild their lives.  Begin setting goals with them the first time you meet them and follow-up on their progress in subsequent appointments.

It is important to address faulty beliefs that may hinder patients from setting effective goals.

  • Help them avoid falling into the trap of thinking that all their pain must be gone in order to set functional goals or to start doing more physical activity.
  • Educate them about the difference between what “hurts” and what “harms” their body.  Knowing that the pain does not cause long-term harm can empower them to work towards functional goals without being worried their actions are causing long-term physical damage.
  • Encourage them to focus on what they can still do, as opposed to what they can no longer do.  It is easy with chronic pain to over-focus on losses, which can have a negative effect on mood and activity level.
  • Also help them avoid setting unrealistic or vague goals, such as “I want to be able to do everything I did before.” Remember to have your patient focus on function, not on the pain.  A person can become lost in their symptoms, and when pain is chronic, focusing on intensity, location, duration, etc., is not necessarily productive.

Six aspects of pain self-management

There are six common areas patients can focus on to better manage their chronic pain:

  1. Exercise (strengthening, stretching, aerobics)
  2. Relaxation/meditation/quieting response
  3. Social support/social activity
  4. Meaningful life activities (work, volunteer, responsibilities to family/church, etc.)
  5. Pleasurable activities (hobbies, interests, diversions, distractions, social)
  6. Attitude/mood/thinking

Clarify goals

Help them identify one area they would like to work on, and then have them set goals in this area during their appointment.  You might say something like,

  • “Let’s work together to come up with some goals for your pain rehabilitation plan.”
  • “How will we both know that you’ve met your goal?”
  • “What would we be able to specifically see you do once you’ve met your goal?”

Other suggestions

Remember to:

  • Discuss goals in the patient’s language.
  • Put goals into the electronic medical record in a place where all the members of the health team can see them.
  • Follow up with the goals at their next visit.
  • Provide positive reinforcement for any attempt taken, as this increases their motivation to adopt a self-management approach to their condition.
  • Anticipate possible barriers and obstacles. Having intentions to work towards a goal only moderately predicts the actual goal-directed behavior.[7]  It is important to have the patient problem-solve how to navigate possible challenges to reach their goal.

Below are examples of what clinicians can offer patients to assist them with self-management of chronic pain.  Note, however, that the VA has specific requirements regarding materials that are directly given to patients, including that materials must be kept at a certain reading level.  Clinicians are invited to offer some of these suggestions as part of what they discuss in a clinic session, but this material is not formally approved to be used as a patient handout.

A Sample Patient Worksheet

Why set working goals?

Rehabilitation starts with well-constructed goals.  Patients should discuss their goals with their clinicians the first time they meet.  Setting goals helps a person focus on what is important in their pain rehabilitation plan and gain some momentum and confidence in learning how to better manage their pain condition.   Chronic pain requires day-to-day management, and setting goals can give people a plan to keep them on track.

Reaching goals lets you know if you are making progress in your pain rehabilitation.  There are many areas that people address when they commit to improving their day-to-day functioning and coping with chronic pain.  Think about these areas and prioritize which areas to work on first.

Setting specific and realistic goals

Problems that have resulted due to pain have not happened over night.  They may have developed over many years.  As a pain condition persists, it is common to experience mood changes (such as depression, anxiety, agitation, frustration and anger), physical deconditioning, weight gain, social isolation, loss of meaningful life activities, changes in identity, decrease in activity, shifts in family roles and responsibilities, changes in work, reduced energy/fatigue, sleep disturbance, concentration/memory problems, increased stress, and unhelpful responses such as catastrophizing or thinking the worst.

Start by making a list of areas to work on.  Common areas to address are:

  • Exercise (strengthening, stretching, aerobics),
  • Relaxation/meditation/quieting response,
  • Social support/social activity,
  • Meaningful life activities (work, volunteer, responsibilities to family/church, etc.),
  • Pleasurable activities (hobbies, interests, diversions, distractions, social, and
  • Attitude/mood/thinking

Note how well these correlate with various parts of the green circle within the “Circle of Health.”

Pick one area that is workable and changeable.  It can be helpful to break the goal down into smaller, specific and reasonable parts.  Begin writing a plan for how to reach the goal.

The 90% confidence rule

Do not expect that a person can be pain-free every day of the week.  This will set them up for failure.  Use the 90% confidence rule to decide whether a goal is realistic.  Here is how it works: If a person is not 90% sure that they can reach that smaller goal within two weeks, they have set the goal too high.  Scale back.

SMART Goal Setting System:

Use the SMART goal setting system to help set precise goals.  A well-written goal allows a person to track progress and answer the question, “Did I achieve this goal?” with a clear “yes” or “no” answer.  By successfully achieving smaller goals, a person can develop the confidence to tackle larger goals in the future. “SMART” stands for: Specific, Measurable, Action-oriented, Realistic, and Timed.

For practice on writing a personal smart goal, please visit this exercise.

Additional Support

It can help to identify one person who can offer support and encouragement as a patient works to attain a goal.  Ask this person to keep the goal setter accountable.  This provides an opportunity for feedback on the process of completing a goal and motivation for future goal setting. Think about a reward for reaching a specific goal; the more motivational, the better.

Author(s)

“Goal Setting for Pain Rehabilitation” was written by Shilagh A. Mirgain, PhD and by Janice Singles, PsyD (2014) and updated in 2016.

References

  1. Filoramo MA. Improving goal setting and goal attainment in patients with chronic noncancer pain. Pain Manag Nurs. 2007;8(2):96-101.
  2. Rockwood K, Stadnyk K, Carver D, et al. A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people. J Am Geriatr Soc. 2000;48(9):1080-1085.
  3. Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Educ Couns. 2006;63(1-2):145-151.
  4. Hartman D, Borrie MJ, Davison E, Stolee P. Use of goal attainment scaling in a dementia special care unit. Am J Alzheimers Dis Other Demen. 1997;12(3):111-116.
  5. Coppack RJ, Kristensen J, Karageorghis CI. Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial. Clin Rehabil. 2012;26(11):1032-1042.
  6. Duggan GB, Keogh E, Mountain GA, McCullagh P, Leake J, Eccleston C. Qualitative evaluation of the SMART2 self-management system for people in chronic pain. Disabil Rehabil Assist Technol. 2015;10(1):53-60.
  7. Sheeran P. Intention—behavior relations: A conceptual and empirical review. Eur Rev Soc Psychol. 2002;12(1):1-36.

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