Hi, welcome to this lecture on goal setting for spasticity management. My name is Dr. Mary Russell, and I'm an assistant professor and vice chair with the University of Texas McGovern Medical School at Houston. I also am medical director at Tier Memorial Hermann in the Woodlands and have an outpatient spasticity practice. I'm on the Speakers Bureau for Xeomin and Botox with MERS and Allergan, respectively. Our learning objectives today are to identify patient goals for spasticity management, identify provider goals for spasticity management, and describe SMART goals. Remember, some people use spasticity functionally. Just because it's there doesn't mean it needs to be treated. So goals should be SMART, which includes specific, measurable, achievable, realistic, and timely. And patient goals should be in line with provider goals to enhance patient outcomes with treatment. Here are some questions to ask when goal setting with a patient. What are the patient's goals? What do the patients or caregivers find difficult to do? Did therapists have trouble overcoming tone, or is there a lack of progress? In which residential setting does the patient live? Is there any availability for post-treatment care, such as therapy? And are there any other explanations for spasticity, such as infection or other causes? So what would be some examples of patient's goals? I've had patients tell me that they want help with pain in their shoulder and their elbow when they're putting their shirt on. I've also had patients who have wanted to decrease their bouncing leg, such as clonus or ankle plantar flexor tone. I've had another patient whose goal was to be able to go to the gym and hold his handle on the weight bar, and that involved his wrist and his finger flexor tone. And another patient that wanted to be able to sit on the horse with their adductor tone. Better goals can include all of the following, but are not limited to decreasing spasms, increasing joint range of motion, facilitating performance of ADLs, decrease abnormal movements or dystonias, increasing active limb movements, improving orthotic fits, improving hygiene and nursing care, decreasing spasm-related pain, preventing contractures, improving transfers and mobility, improving position, gait, and preventing skin breakdown. So what are SMART goals? SMART goals are goals that are specific, measurable, achievable, realistic, and timely. So a specific goal is one that's well-defined, it's clear, and is non-ambiguous. A measurable goal is one with specific criteria that measures progress, such as range of motion. Or the modified Ashworth scale. Achievable means that goals are attainable and not impossible to achieve. Realistic means that they're within reach, and timely is a clearly defined timeline. So an example of a SMART goal would be the patient's goal to be able to sit on a horse in hypotherapy. In order to accommodate that, you'd want to address adductor spasticity by improving the adductor range of motion, as well as the modified Ashworth scale. You can have a measurable goal, one that is specific. It can certainly be achievable, realistic, and it also can occur within a specified timeline. So when you're looking at specificity, you want to look at who is involved, what will be accomplished, where is this goal to be achieved, when do I want to achieve this goal, and why do I want to achieve this goal? So if we are looking at that patient that we used this example before, the patient and the caregiver is the one that is involved. What are you looking at being accomplished is decreasing tone. You want to achieve that as soon as possible. And why do you want to achieve it? You want to ease caregiver burden, improve the quality of life, and improve hygiene. Measurable goals, you can ask yourself, how many and much? How do I know if I reached my goal? So in this scenario, we know the patient has reached their goal if they're able to ride the horse without pain and have improved positioning. What could be an indicator of progress could be the modified Ashworth score that shows improvement, as well as patient and caregiver report. When you're looking at goal setting and what is achievable, you want to ask yourself, what are the resources and capabilities to achieve the goal? And have others been successful? In this scenario, has the patient tried any therapy, splints, oral medications, other injectables, or intrathecal therapy? And have others been successful? Has the patient previously tried any of those therapies? What's worked or didn't work? In this scenario, the patient had an intrathecal baclofen pump but still presented with dynamic tone. For goal setting, you also want to look at, is the goal realistic? Is it achievable given time and resources? And is the patient and provider able to commit to achieving the goal? So you want to ask yourself, does the patient have therapy available? Do they have splints or staff that's able to assist with donning and doffing splints if they're unable to do so themselves, as well as range of motion and stretching? And are they able to commit to achieving the goal? Do they make their appointments? Are they compliant with treatment and their home exercise program, medications? Do they have reliable transportation? Those are just some of the things that you want to look at. So you also want to ask yourself, when do you want to achieve your goal? And does it have a deadline? So in this scenario, the patient wanted to achieve their goal by the next therapy session. And ideally, you would want to be able to have your goal by the end of the next therapy session. And ideally, you would want to be able to have improved range of motion in the time prior to the completion of therapy. So which of the following can be a goal of treatment for spasticity? A, decrease pain. B, it's easier to don their wrist hand orthosis. C, improve spasms. C, improve spasms. Or D, all of the above. The correct answer is D. Patient, caregiver, and provider goals can include all the following, but are not limited to decreasing spasms, decreasing spasm-related pain, increasing joint range of motion, preventing contractures, facilitating performance of ADLs, improving transfers and mobility, decreasing abnormal movements or dystonias, improving positioning, increasing active limb movement, improving gait, orthotic fit, improving hygiene and nursing care, and preventing skin breakdown. So there are a few things to take away from this talk today. One is that not all spasticity needs treatment. Some patients do use spasticity functionally. Goal setting is of the utmost importance, and patient and provider goals should be aligned and frequently revisited to ensure compliance with treatment as well as successful outcomes.

spasticity management

SMART goals

patient objectives

treatment outcomes

daily activities