You are not logged in. Press here to login.


List volumes - List articles in this issue

Original report

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

doi: 10.2340/16501977-0474

Open access


OBJECTIVE: To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with botulinum toxin-A.
DESIGN: Secondary analysis of a multi-centre double-blind, placebo-controlled randomized clinical trial.
SETTING: Six outpatient clinics in Australia.
PARTICIPANTS: Patients (n = 90) completing per protocol 2 cycles of treatment/placebo. Mean age 54.5 (standard deviation 13.2) years. Mean time since stroke 5.9 (standard deviation 10.5) years.
Interventions: Intramuscular botulinum toxin-A (Dysport ® 500–1000U) or placebo given at 0 and 12 weeks. Measurement points were baseline, 8 and 20 weeks.
Main outcome measures: Individualized goal attainment and its relationship with spasticity and other person-centred measures – pain, mood, quality of life and global benefit.
RESULTS: A significant treatment effect was observed with respect to goal attainment (Mann-Whitney z = –2.33, p ≤ 0.02). Goal-attainment scaling outcome T-scores were highly correlated with reduction in spasticity (rho = 0.36, p = 0.001) and global benefit (rho = 0.45, p < 0.001), but not with other outcome measures. Goal-attainment scaling T-scores were lower than expected (median 32.4, interquartile range 29.6–40.6). Goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience.
CONCLUSION: Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures.


Lynne Turner-Stokes, Ian J. Baguley, Stephen De Graaff, Pesi Katrak, Leo Davies, Paul McCrory, Andrew Hughes


  1. Bakheit AM, Sawyer J. The effects of botulinum toxin treatment on associated reactions of the upper limb on hemiplegic gait – a pilot study. Disabil Rehabil 2002; 24: 519-522.
  2. Bhakta BB, Cozens JA, Chamberlain MA, Bamford JM. Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial. J Neurol Neurosurg Psychiatr 2000; 69: 217–221, erratum 821.
  3. Bhakta BB, Cozens JA, Bamford JM, Chamberlain MA. Use of botulinum toxin in stroke patients with severe upper limb spasticity. J Neurol Neurosurg Psychiatr 1996; 61: 30–35.
  4. Brashear A, Gordon MF, Elovic E, Kassicieh VD, Marciniak C, Do M, et al. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke [comment]. New Engl J Med 2002; 347: 395–400.
  5. Hesse S, Jahnke MT, Luecke D, Mauritz KH. Short-term electrical stimulation enhances the effectiveness of Botulinum toxin in the treatment of lower limb spasticity in hemiparetic patients. Neurosci Lett 1995; 201: 37–40.
  6. Richardson D, Edwards S, Sheean GL, Greenwood RJ, Thompson AJ. The effect of botulinum toxin on hand function after incomplete spinal cord injury at the level of C5/6: a case report. Clin Rehabil 1997; 11: 288–292.
  7. Rodriquez AA, McGinn M, Chappell R. Botulinum toxin injection of spastic finger flexors in hemiplegic patients. Am J Phys Med Rehabil 2000; 79: 44–47.
  8. Simpson DM, Alexander DN, O‘Brien CF, Tagliati M, Aswad AS, Leon JM, et al. Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled trial. Neurol 1996; 46: 1306–1310.
  9. Smith SJ, Ellis E, White S, Moore AP. A double-blind placebo-controlled study of botulinum toxin in upper limb spasticity after stroke or head injury. Clin Rehabil 2000; 14: 5–13.
  10. Ashford S, Turner-Stokes L. Goal attainment for spasticity management using botulinum toxin. Physiother Res Int 2006; 11: 24–34.
  11. Francis HP, Wade DT, Turner-Stokes L, Kingswell RS, Dott CS, Coxon EA. Does reducing spasticity translate into functional benefit? An exploratory meta-analysis. J Neurol Neurosurg Psychiatr 2004; 75: 1547–1551.
  12. Childers MK, Stacey DOM, Cook DL, Stonnington HH. Comparison of two injection techniques using botulinum toxin in spastic hemiplegia. Am J Phys Med Rehabil 1996; 75: 462–469.
  13. Spasticity in adults: management using botulinum toxin. National guidelines. London: Royal College of Physicians; 2008.
  14. Kiresuk T, Sherman R. Goal attainment scaling: a general method of evaluating comprehensive mental health programmes. Com Mental Health J 1968; 4: 443–453.
  15. 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: 581–588.
  16. Williams RC, Steig RL. Validity and therapeutic efficiency of individual goal attainment procedures in a chronic pain treatment centre. Clin J Pain 1987; 2: 219–228.
  17. 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: 652–659.
  18. Schlosser RW. Goal attainment scaling as a clinical measurement technique in communication disorders: a critical review. J Communication Disord 2004; 37: 217–239.
  19. Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: a systematic review. Clin Rehabil 2006; 20: 756–772.
  20. 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: 823–829.
  21. 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: 274–282.
  22. Becker H, Stuifbergen A, Rogers S, Timmerman G. Goal attainment scaling to measure individual change in intervention studies. Nurs Res 2000; 49: 176–180.
  23. Malec JF, Smigielski JS, DePompolo RW. Goal attainment scaling and outcome measurement in postacute brain injury rehabilitation. Arch Phys Med Rehabil 1991; 72: 138–143.
  24. 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: 736–743.
  25. 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: 550–556.
  26. Tennant A. Goal attainment scaling: current methodological challenges. Disabil Rehabil 2007; 29: 1583–1588.
  27. 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: 735–742.
  28. 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 randomised placebo-controlled study of the effects on quality of life and other person-centred outcomes. J Rehabil Med 2009; 41: 536–544.
  29. Hawthorne G, Richardson J, Osborne R. The Assessment of Quality of Life (AQoL) instrument: a psychometric measure of health-related quality of life. Qual Life Res 1999; 8: 209–224.
  30. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth Scale of muscle spasticity. Physical Ther 1987; 67: 206–207.
  31. Rushton PW, Miller WC. Goal attainment scaling in the rehabilitation of patients with lower-extremity amputations: a pilot study. Arch Phys Med Rehabil 2002; 83: 771–775.
  32. Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scand 1983; 67: 361–370.
  33. World Health Organization. International classification of functioning, disability and health. Geneva: World Health Organisation; 2002.
  34. Cieza A, Brockow T, Ewert T, Amman E, Kollerits B, Chatterji S, et al. Linking health-status measurements to the international classification of functioning, disability and health. J Rehabil Med 2002; 34: 205–210.
  35. Stucki G, Grimby G. Forward: Applying the ICF in medicine. J Rehabil Med 2004; 36: 5–6.
  36. Soberg HL, Finset A, Roise O, Bautz-Holter E. Identification and comparison of rehabilitation goals after multiple injuries: an ICF analysis of the patients’, physiotherapists’ and other allied professionals’ reported goals. J Rehabil Med 2008; 40: 340–346.

Related articles

There are no related articles.



Full text



There is no supplementary for this article.

Related articles

Click here to show related articles

Print information

Volume 42, Issue 1

DOI: 10.2340/16501977-0474

Pages: 81-89

View at PubMed