on Patient Compliance with. Physiotherapy Exercise. Program mes. Summary Treatment goals are a motivational tool commonly used by physiotherapists to ...
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Summary Treatment goals are a motivational tool commonly used by physiotherapists to improve patients’ compliance with exercise programmes. This study investigated their effectiveness in meeting this aim. Sixty-six patients starting a new course of physiotherapy and having exercises as part of their treatment, were randomly allocated to one of the three experimental goal groups: physiotherapist-participant collaborative, physiotherapistmandated, and no formally set goals. The number of sessions and repetitions they performed for each exercise was recorded in a diary Data showed there were no significant differences between the groups on overall compliance. However, analysis of range of movement and muscle strength data showed the no formally set goals group to be significantly more compliant than the physiotherapist-mandatedgroup. Further analysis revealed that those participants in the collaborative group who had range of movement or both muscle strength and range of movement measurements were significantly more compliant with the recommended exercise repetitions than those in the physiotherapist mandated group. The results of this study indicate that treatment goals may not be a suitable motivational tool for all people, but if they are to be used in physiotherapy, collaboratively set goals appear to lead to a higher level of treatment compliance than physiotherapist-mandatedgoals. .Introduction ........... .. .. ....... ........, ...,....... ..... .. ..... ....,., ,,...., .... .... . .. ....,......... ,
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Key Words ! Compliance, physiotherapy, j exercises, goals.
The Effect of Treatment Goals on Patient Compliance with Physiotherapy Exercise Programmes
Bassett, S F and Petrie, K J (1999). ‘Tht: el’fect o f irci~lt.r~lcr~t, goals on patient cornpliancc with physiotherapy exercise progr;mines’, I’ly.s&h~?r~~@, 85, 3,
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Compliance is defined as the extent to which patients adopt the behaviours and treatment recommended by their practitioners (Taylor, 1995). Non-compliance is a mdjor problem in physiotherapy as it is With other torms of medical treatment (Kaplan and Simon, 1990; O’Brien et al, 1992). Recently, in the Netherlands, Sluijs et a1 (1993) studied compliance with physiotherapy exercise programmes, and found that while 35% of patients reported that they did their exercises very regularly, 22% indicated that they did not d o their prescribed exercises at all or only very occasionally. Research suggests that
PhysiotherapyMarch 1!~99/vol85/no 3
j by Sandra F Bassctt j Keith J Petrie
compliance with treatment can be enhanced if patients understand the rationale and the importance of their role in recovery (Meichenbaum and Turk, 1987). The use of educational and behavioural modification methods such as treatment goals is assumed to be a probable way of improving this understanding (Ley, 1988; Locke and Bryan, 1967). While treatment goals are used frequently in physiotherapy, there is debate about their effectiveness in improving compliance (May, 1993; Riolo, 1993; Sluijs et a& 1993). The behavioural changes required for exercising, such as altering daily routines to include exercise sessions, are thought to contribute to the poor compliance with exercise programmes, particularly at the time of initiation of the programme (Dishman, 1987). However, during the acute stage of disorders, patients’ symptoms may act as a prompt to exercise especially if they are relieved by it. Unfortunately, about a third of people attending physiotherapy have chronic recurrent disorders which benefit from exercises as a preventive measure irrespective of the intensity of symptoms. In these cases, it is lack of symptoms which is thought to contribute to poor levels of compliance (Sluijs and Knibbe, 1991). Nevertheless, there are some people who, irrespective of the intensity of the symptoms, seem to be motivated enough to persist with their recommended treatments (Dishman, 1991; Knapp, 1988; Sluijs and Knibbe, 1991). Consequently, it has been suggested that the use of motivational techniques may help people to continue with therapeutic exercise programmes, especially when the symptoms are no longer present to act as cues (Dishman, 1987; Meichenbaum and Turk, 1987; Sluijs and Knibbe, 1991).
Professiona1 articles
Treatment goals are considered to be one method of motivating patients to comply with long-term treatment programmes which have an exercise component (Falvo, 1985; Stenstrom, 1994). The use of patientphysiotherapist collaboratively set goals for rheumatoid arthritic patients who undertook a home exercise programme was studied by Stenstrom (1994). These goals were set individually with each patient to suit ’his or her exercise needs. It was found that 77% of the participants in the collaborative group ‘increased their exercise load, compared with 20% of subjects in the no goals group. These results seem to support the rlotion that meaningful, realistic goals are set when there is colkaboration between the patient and clinician (Haas, 1993; Keefe and Blumenthal, 1980; Partridge, 1990; Tubbs, 1986). For these reasons collaborative goals may be more effective than those set solely by a.clinician (Cott and Finch, 1991; Stenstrom, 1994; Tubbs, 1986). However, not all research totally supports the use of treatment goals as a motivational technique. Roth Cott and Finch (1991) and Northen et a1 (19%) found that physiotherapists and occupational therapists respectively tended to place less emphasis on treatment goals which were based on patients’ needs and daily activities. Cott and Finch (1991) reported that physiotherapists appear to have difliculty in the initial stages of treatment programmes predicting an achievable outcome in a given time for each of their patients. In a similar way the goals that patients frequently suggest may be u n r e a h i c for their capabilities. The end result seems to be that physiotherapists feel more comfortable telling their patients what the recommended treatment is expected to achieve as opposed to setting treatment goals with them. In their study of the use of collaboratively set treatment goals in occupational therapy Northen et al (1995) found that therapists did not maximise patients’ and their families’ potential in goal setting process. While the patients were involved in the goal setting, 86% .of the 30 occupational therapists in this study failed to discuss with their patients exactly what this involvement could be in the treatment goal setting and planning. In addition, a similar number of these therapists failed to elicit the patients’ concerns and then prioritise them. As a consequence, they did not base the treatment goals on these concerns. Payton
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and Nelson (1996) had similar conflicting findings about the use of treatment goals in physiotherapy. They found that while physiotherapists believed the treatment goals had been set with patients in a collaborative manner, some patients did not agree. In spite of the physiotherapists establishing the benefits that the patients wanted to get from the proposed treatment, the patients believed that there was an inevitable standard long-term goal, which was ‘to restore them to their previous level of function’. Hence it appears that the effectiveness of treatment goals depends to some extent on their construction and implementation. It has been proposed that goals should be challenging, achievable, specific, measurable, meaningful and predict a time for evaluation. Goals with these qualities are considered to encourage motivation (Cott and Finch, 1991; Falvo, 1985; Knapp, 1988; Nicholson and Tobaben-Wyssmann, 1984; Partridge, 1990). Furthermore, these qualities need to be reflected in the wording of the goals. Zuck and Singer (1980) explained that goals which a‘;e based on patients’ daily activities and written in their everyday language appear to be more meaningful than those worded in clinicians’ terminology. Consequently, these qualities are considered to give patients a sense of purpose in their treatment (Nicholson and Tobaben-Wyssmann, 1984; Payton et al, 1990). Similarly, long-term goals are thought to be more achievable if they are broken down into a series of more immediate shortterm goals (Payton et al, 1990). While treatment goals are believed to encourage people to comply with exercise programmes, there still is some controversy over their motivational value. On the basis of the results of two studies undertaken by Wankel et al (l985), it could be argued that other motivational techniques may be just as effective. They tested the use of decision balance sheets and structured social support as motivational techniques to encourage people to continue to undertake formal exercise programmes. Their findings indicated that both of these techniques were better than no motivational method. Riolo (1993) also believes that the effectiveness of treatment goals for improving patient compliance with physiotherapy has not been clearly established, and needs further investigation. Consequently, the purpose of this study was to test the effect of treatment goals on
Authors Sandra F Bassett MHSc BA DipPhty is a senior lecturer in the School of Physiotherapy, Auckland Institute of Technolobv. Keith J Petrie PhD is an associate profcssor in the Department of Psychiatry and Behavioural Science, The University of Aucklan’d. This article was received on August 10, 1997, and accepted on August 17, 1998.
Address for Correspondence Sandra F Bassett, School of Physiotherapy, Auckland Institute of Technology, Private Bag 92006, Auckland, New Zealand. Acknowledgments Funding from the Maurice and Phyllis Paykel Trust and the New Zedand Society of Physiotherapists Scholarship Trust support.edthis research. The authors also express their gratitude to the physiotherapists and patients who participated in this study.
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patient compliance with physiotherapy exercise programmes. This was undertaken by comparing the use of collaborative patient-physioth erapist goals with physiotherapist mandated goals and no formally set goals. These three levels of treatment goals were the basis for the three comparison groups in this study. Collaborative patient-physiotherapist goals were those based on the daily activities the patients wished to achieve and modified by physiotherapists to ensure that they were realistic, whereas physiotherapist-mandated goals were set solely by a physiotherapist and based on the movement deficits of patients. Those who did not have any formally set goals were just given the exercises, the reasons for doing them and instructions on how,to perform them. It was hypothesised that the participants in the collaborative goal group would have a higher level of compliance with their home exercises than those in the physiotherapist-mandated and those in the no formally set goal groups. For this study the definition used for compliance was based on that of Taylor (1995), but adapted to suit the needs of the use of exercise programmes in physiotherapy and was ‘the extent to which a person’s behaviour coincides with the exercise programme given by the physiotherapist’.
Method Participants Seventeen physiotherapists volunteered to take part in the study, with 15 of them practising in the private sector and two in the public sector. They enrolled 74 suitable patients in this study. Participants were approached to take part in the study if they had a diagnosed limb injury and were starting a new course of physiotherapy, which required exercises to practise at home. Those participants attending private clinics had their treatment costs paid for by the New Zealand Accident Compensation Corporation as their injuries were as a result of accidents. Eight participants were withdrawn from the study because they did not complete their courses of physiotherapy. The final sample consisted of 66 participants, 55 of whom had previously had physiotherapy for some other problem. There were 32 males and 34 females, whose ages ranged from 13 to 72 years (X = 40.76, SD f 16.15).Twenty-seven of the participants had upper limb injuries and 39 had lower limb injuries. Physiotherapy March 1999/vol85/no 3
Measures Participants were provided with an exercise diary in which they recorded their home exercise behaviours. At each home exercise session they were required to record on a grid the number of sessions and repetitions completed for each of their prescribed exercises they performed. The two treatment goals groups had their goal sheets attached to their diaries, whereas the no set goals group did not have these sheets. Range of movement and muscle strength measurements were taken if the participants had a deficit in one or both of these when compared with the corresponding part of the opposite limb. All physiotherapists were instructed to use the same methods of measurement. Standard goniometers were used for measuring ranges of movement, recorded in degrees. Muscle strength was measured using the percentage of muscle strength scale developed by Kendall et a1 (1971). These measurements were recorded at the time of their enrolment on the study and at the end of the participants’ courses of physiotherapy. A comparison of each of these measurements was expressed as a percentage of improvement. The rate and degree of symptom relief were measured by the number of treatments the participants required and a three-point rating scale where 1 was complete relief of symptoms as a result of the physiotherapy, 2 was partial relief and 3 was no relief respectively. These data were recorded at the end of the treatment phase of the study. Procedure With ethical committee approval and informed consent, participants were randomly allocated to one of the three treatment goal-setting conditions, participant-physiotherapist collaborative (n = 23), physiotherapist-mandated (n = 22) or no formally set goals (n = 21) groups. The long-term treatment goals for those in the goal-setting groups were established during the initial treatment session. These goals were then broken down further into more immediate achievable short-term goals at this session. At subsequent treatment sessions these short-term goals were altered to meet the changing needs of the participants’ conditions. The method for setting these goals was different for each group. Both the participants and the physiotherapists were involved in setting the goals for those in the collaborative group. The goals for these participants were based on
Professiona I a rtides
the daily functional activities they wished to achieve, and what the physiotherapists thought were realistic. For example a longterm goal for participants in this group could have been ‘to be able to play a full game of rugby within three weeks’. A typical short-term goal for these participants might have been ‘to climb a flight of stairs normally by the eighth treatment’. Physiotherapists set the goals for the participants in the physiotherapist-mandated goals group. These goals were written in language that the participants understood, but were based on overcoming their movement deficits. For example a long-term goal for a participant in this group with a knee injury could have been ‘to gain full range knee movement within three weeks’. ‘Obtain 90” of knee bending by the fifth treatment’ would have been an example of a short-term goal, which could have been used to achieve the long-term goal. All participants were taught how to use the exercise diaries during this treatment session, and were instructed to complete them at each exercise session. Irrespective of their goal group, the participants helped their physiotherapists with writing the exercises in their diaries, so that their wording was meaningful. When the participants’ conditions changed, their exercises were altered accordingly. This necessitat.ed that their exercise diaries and goal sheets also had to be altered to meet their changing requirements. At the end of the participants’ courses of treatment their exercise diaries and goal sheets were collected. The number of treatments required by the participants to obtain relief was also recorded at this stage and they were asked to indicate on the three-point scale (described previously in the measures section) the amount of relief they gained from their course of physiotherapy. Before the data collection phase, all the physiotherapists were given both oral and written instructions about the purpose and procedure of the study. The written information took the form of a booklet, which contained the method, and two types of goal setting, the use of the exercise diaries and use of the measuring instruments. To help the physiotherapists, one of the researchers undertook some of the data collection by obtaining the demographic information and measuring the joint range of movement and muscle strength. However, that researcher was not involved in any of the treatment goal setting.
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Data Analysis For each exercise that participants were given, their diary recordings were expressed as percentages of the sessions and the repetitions which had been recommended by their physiotherapists. Mean compliance percentages were then calculated for the exercise repetitions and the exercise sessions for each participant. Both of these outcome variables were normally distributed (exercise repetitions skewness = -0.76; kurtosis = -0.27; exercise sessions skewness = - 0.82; kurtosis = -0.27). These data were then analysed using the Statistical Package for Social Sciences at a significance level of 0.05. Analysis of variance (ANOVA) was used to analyse the group differences. When this analysis identified a significant difference between the groups, a post hoc Tukey-B test was used to establish which groups differed from each other. .Results .... . ..... .... ..... .... ........ ........ ......... . ..... ..... ......... The mean number of treatments for the total sample was 12.79 (SD f 8.33), &th the physiotherapist-mandated goals group requiring slightly fewer treatments ( R = 11.46, SD f 5.40). The other two groups needed slightly more treatments, with the collaborative goals group having a mean of 13.61 (SD f 8.01) and the no formally set goals group having a mean of 13.29 (SD 11.01). No statistical differences occurred between the groups for the number of treatments required (F(2,63) = 0.42, ns). As stated above, the amount of symptom relief obtained from physiotherapy was measured on a three-point scale from 1 (complete relief) to 3 (no relief). The mean amount of relief obtained from physiotherapy by the sample was 1.62 (SD f 0.52). No significant difference was found between the groups for the amount of relief obtained (F(2,63) = 0.64). The amount of relief obtained by each group was very similar, with the collaborative goals group obtaining slightly more (X = 1.52, SD f 0.51) than the physiotherapist-mandated (X = 1.68, SD k 0.57) and the no formally set (X = 1.67, SD f 0.48) goals group. Irrespective of the goal groups, the sample’s mean compliance percentage for the number of sessions was 73.55 (SD f 20.92), and 70.15 (SD k 21.80) for the number of repetitions. There were n o significant differences between the three groups for the number of repetitions they performed for each exercise (F(2,63) = 3.01, ns), or the number of exercise sessions they , ,,,
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undertook (F(2,63) = 2.58, ns). The no formally set goals group was slightly more compliant with their exercise sessions (X = 79.57%, SD f 17.07) and repetitions (X = 75.62%, SD 20.96) than the colkaborative group were for their number of sessions ( X = 75. 4396, SD f 20.88) and repetitions (X = 73. 74%, SD k 20.88). The physiotherapist-mandated group was the least compliant for both the number of sessions (X = 65.82%, SD f 23.65) and the repetitions they performed (X = 61.18%, SD k 21.63). Further analysis of these data was performed for those participants who had percentage improvement scores for range of movement, and those who had muscle strength scores. Fifty-two participants had percentage improvement scores for their muscle strength and the analysis of their compliance data is presented in table 1 . AN OVA r eve a1e d sign if i can t group differences for the number of exercise sessions and repetitions performed. A post hoc Tukey-B test indicated that the n o formally set goals group was significantly
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Table 1: Mean percentages of compliance for the number of repetitions and exercise sessions for the participants who had muscle strength measurements Parameter
Goal setting groups Collaborative Mandated n=20 n=14
No set n=16
F (df = 2.47) Significance
Sessions
73.68 20.31
60.71a 23.01
79.94” 19.66
3.62
0.03
SD Repetitions R SD
72.26 20.70
56.41a 20.95
76.75a 23.77
4.05
0.02
ji
aDenotes differences between the groups significant at 0.05 level (Tukey-B test)
Table 2: Mean percentages of compliance with the number of repetitions and exercise sessions for each goal group’s participants who had range of movement measurements Parameter
Sessions X
SD
Goal setting groups Collaborative Mandated n =20 n=14
No set n=16
F (df = 2.47) Significance
75.10 19.94
61.43a 26.44a’
83.13a 12.45
4.42
0.02
74.30b 21.21
56.64a’ 24.47
81.25a 11.80
6.08
0.0052
Repetitions jr
SD
Denotes differences between the groups significant at 0.05 level (Tukey-B test)
Physiotherapy March 1999/vol %/no 3
more compliant than the physiotherapistmandated goals group with their physiotherapists’ recommendations for both the number of repetitions and sessions undertaken. The collaborative group did not differ from either of the other two groups for the number of repetitions or the number of sessions they undertook. Fifty participants had percentage improvement scores for their range of movement and significant group differences were apparent for the number of exercise repetitions and the number of exercise sessions. The post hoc Tukey-B tests indicated that the no formally set goals group was significantly more compliant than the physiotherapist-mandated group for both the number of repetitions and the number of sessions undertaken. However, the collaborative goals group was significantly more compliant than the physiotherapistmandated group for the number of repetitions performed. The mean percentages of compliance for the exercise sessions and the number of repetitions, and the number of participants in each group are presented in table 2. The exercise diary data for the 39 participants who had both range of movement and muscle strength scores also showed significant differences by group. Significant differences were found for the exercise sessions done (F (2,36) = 5.33, p < 0.01), and the number of repetitions performed (F(2,36) = 8.37, p < 0.001). Once again, participants in the no formally set goals group were more compliant with the recommended number of exercise sessions (X = 84.83%, SD f 14.04) compared with those in the collaborative group ( X = 72.94%, SD f 20.36) and those in physiotherapist-mandated goals group ( X = 56.73%, SD +. 26.42). A similar pattern occurred for the number of exercise repetitions with the no formally set goals group having a higher score (X = 83.67%, SD k 12.29) than the collaborative group (X = 72. 69%, SD f 21.14) and the physiotherapist-mandated group (X = 50.91, SD & 23.08). The post hoc Tukey-B test revealed that members of the no formally set goals group were significantly more compliant than the physiotherapist-mandated goals group with both the number of exercise repetitions and sessions that they did. The n o formally set goals group did not, however, differ significantly from the collaborative group with the number of exercise sessions they did, although the
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collaborat.ive group was significantly more co m p 1i a n t L h an the p h y s i o t h e r ap i s tmandated goals group for the number of exercise repetitions. These results showed a similar pattern to those of all of the participants in the study, and the group differences are shown in the figure. 100
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Repetitions Sessions Group mean scores Collaborative goals
Mandated goals
NO set goals Mean percentages of compliance with exercise repetitions and sessions for participants who had both range of movement and muscle strength scores .Discussion .. ........... .... ....... ............ .. ......., .. .. .. .. .......... .. ...... .. ... .. .... .. ..... .... .
The findings of this study seem to contradict the notion that treatment goals have a positive effect on patient compliance. All of the data analyses showed that the no formally set goals group had higher compliance percentages than the two goal groups, although the collaborative group was consistently more compliant than the mandated group. On the basis of these results, the hypothesis that the participantphysiotherapist collaborative goal group would have a higher level of compliance with their home exercises than the other two groups, was only partially supported. As t.he goal setting groups were shown to be no different in terms of the amount and rate of recovery, their compliance levels do not seem related to these factors. It. seems therefore that the motivation of the participants to comply, the type of treatment goals and the educational techniques used
may have influenced the outcomes of this study. Several possible reasons may account for the higher compliance level of the no formally set goals group. First, it is recognised that people who volunteer to take part in research tend to be more motivated than those who choose not to participate (Oyster et al, 1987). Also, both Dishman (1991) and Knapp (1988) believe that people who consider that exercises are beneficial for their disorder tend to be motivated to persevere with them. Secondly, while the possibility that some of the participants in the no formally set goals group may have used their own motivational techniques to continue to exercise was not established, it could be that they set their own goals. This notion can be supported by Dzewaltowski’s (1994) belief that some people will do this when they have something they wish to achieve. In turn, the satisfaction gained as a result of this achievement may have further encouraged them to perform even better. In addition, some of these participants may have used some other strategy to motivate themselves. This interpretation could be explained by the hypothesis of Wankel et aZ(1985) that as no single motivational technique is superior, they should be selected to suit the individual. It has also been shown that there are people who do not require incentives to complete required tasks successfully (Dishman, 1991; Knapp, 1988; Locke and Bryan, 1967; Sluijs and Knibbe, 1991), which may have occurred in the no formally set goals group. Thirdly, the compliance percentages were highest for those participants in the no formally set goals group who had both range of movement and muscle strength scores. This could indicate that the restricted joint movement and muscle strength may have prompted these people to exercise. Acute symptoms, which interfere in people’s lives, tend to be associated with higher levels of compliance (Groth and Wulf, 1995). Hence, such symptoms may act as cues to exercise (Dishman, 1987; Sluijs and Knibbe, 1991). The participant-physiotherapist collaborative group had consistently higher compliance levels than the physiotherapistmandated group. The goals for each group were constructed so that they adhered to the principles considered to motivate people to achieve (Cott and Finch, 1991; Falvo, 1985; Knapp, 1988; Nicholson and TobabenWyssmann, 1984; Partridge, 1990). The only physiotherapy March 1999/vol %/no 3
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differences were in their content and wording, with the collaboratively set goals based on the daily activities the participants wished to achieve. When setting a time span for goal achievement, the participants in the collaborative group frequently offered unrealistically short time limits for goal achievement. This situation usually led to a more sensible time span being set by physiotherapists in consultation with the participants, whereas the mandated goals were based on the physiotherapists’opinions of the participants’ ability to improve their movement and function. The greater involvement of the collaboratively set goals group involvement in the goal setting may have been responsible for its higher level of compliance. This supports the suggestion that these types of goals tend to be more meaningful and realistic for patients (Haas, 1993; Kee4‘e and Blumenthal, 1980; Meichenbaum and Turk, 1987; Partridge, 1990; Tubbs, 1986; Zuck and Singer, 1980). Similarly, Stenstrom (1’394) found that the use of collaboratively set goals for an exercise programme for people who had rheumatoid arthritis led to an increase in exercise load. Furthermore, the consistently better compliance levels of the collaborative group when compared with the mandated goals group seem to contradict the findings of Cott and Finch (1991) and those of Northen et aZ(1995). These researchers reported that physiotherapists and occupational therapists seem to have difficulty incorporating the patients’ specific daily activities into the treatment goals. Several other factors appear to have had some effect on this study’s results. Generally, the physiotherapists tended to give only a few simple exercises, with the instructions usually being to perform these three times daily, with ten repetitions of each exercise being done at each session. All participants had their exercises written in their diaries in language which was meaningful for them. The exercise information was also given orally. These methods of presenting health information are considered by Ley (1988) to enhance patients’ understanding and ultimately improve their compliance. In addition, the physiotherapists fulfilled the ethical requirements of informing their
patients about the available methods of treatment. As a consequence, it was difficult for them not to involve the no formally set goals group in the treatment planning process. There are some weaknesses in this study, which may have also affected its outcomes. While treatment diaries were the most viable method of measuring patient compliance, Turk and Rudy (1991) explain that they can act as a prompt to exercise, which may have influenced the data. Participants’ levels of pain were not assessed. As many of the participants presented with pain, it would have been of value to know whether it acted as a cue for exercising. It must also be acknowledged that the large numbers of physiotherapists who took part may have led to a lack of uniformity in the implementation of the goal setting procedures.
Conclusions It appears that more research into the use of treatment goals in physiotherapy treatment programmes is needed. As many of the patients who have physiotherapy suffer from chronic recurrent disorders, it would be of value to undertake a similar study of people with such conditions. The intermittent nature of these disorders tends to predispose patients to lapses in compliance (Sluijs and Knibbe, 1991), and the reputed motivational effect of treatment goals may be one way of overcoming this problem. Finally, despite the no formally set goals group being the most compliant with the physiotherapists’exercise recommendations, the participant-physiotherapist collaborative goal group had a consistently higher level of compliance than the physiotherapistmandated goals group on all the analyses of the exercise diary data. As a consequence of this study, it is suggested that if treatment goals are to be used clinically to improve compliance they should be set in consultation with patients. However. the compliance levels of the no formally set goals group may be an indication that treatment goals are not suitable for everyone.
Professiona I a rtides
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