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RehabMeasures Instrument

Goal Attainment Scale

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Purpose

The Goal Attainment Scale (GAS) is an individualized outcome measure involving goal selection and goal scaling that is standardized in order to calculated the extent to which a patient’s goals are met.

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Instrument Details

Acronym GAS

Area of Assessment

Activities of Daily Living
Aphasia
Balance – Vestibular
Balance – Non-vestibular
Behavior
Cognition
Communication
Coordination
Depression
Developmental
Dysarthria
Functional Mobility
Gait
General Health
Infant & Child Development
Life Participation
Mental Health
Pain
Quality of Life
Range of Motion
Reading Comprehension
Seating
Social Relationships
Spasticity
Strength
Upper Extremity Function
Incontinence

Assessment Type

Patient Reported Outcomes

Administration Mode

Computer

Cost

Not Free

Cost Description

Cost not known

Diagnosis/Conditions

  • Brain Injury
  • Cerebral Palsy
  • Pain Management
  • Parkinson's Disease + Neurologic Rehabilitation
  • Sports Medicine
  • Stroke Recovery
  • Vestibular Disorders

Key Descriptions

  • Each patient effectively has their own outcome measure, but these measures are scored in a standardized way. “Successful” outcomes are agreed upon prior to intervention.
  • Scoring: Each goal is rated on a 5-point scale:
    +2 = much more than expected
    +1 = somewhat more than expected
    0 = Patient achieves the expected level
    -1 = somewhat less than expected
    -2 = much less than expected
  • Overall score is calculated by incorporating the goal outcome scores into a single aggregated t-score.
  • Optional - goals may be weighed by the patient for importance or difficulty.

Number of Items

1-6

Equipment Required

  • Pen or Pencil
  • GAS form that clinician and patient and/or proxy fill out together

Time to Administer

5-60 minutes

Rushton (2002): 20-60 minutes for goal setting
Steenbeek (2007): 45 minutes per child to develop a scale
Bouwens (2008): Less than 30 minutes to administer
Stolee (1999): 5-10 minutes, per patient, at rounds

Required Training

Training Course

Age Ranges

Infant

0 - 2

years

Preschool Child

2 - 5

years

Child

6 - 12

years

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by:  Austin Bloomburg, SPT; Kelcie Bradham, SPT; Jessi Groves, SPT; Michael Jeanfavre, SPT; Laura Martens, SPT; Jennifer Pike, SPT; Kaitlyn Schlueter, SPT; Joshua Staggs, SPT; Courtney Williams, SPT.

Body Part

Head
Neck
Upper Extremity
Back
Lower Extremity

ICF Domain

Body Function
Activity
Participation
Environment

Measurement Domain

Activities of Daily Living
Cognition
Emotion
General Health
Motor

Considerations

  • Cytrynbaum (1979): The widespread use of GAS has been accompanied by serious violations of assumptions and requirements which are basic to the original model. (1) randomly assigning subjects to therapists or treatment conditions (2) Follow up raters and goal selectors be independent of service deliverers. (3) “mental health service involves very difficult and complex decision making which requires considerable clinical sophistication” – consider training (4) remember to establish initial status of client at baseline 

  • Schlosser (2003): Recommends that independent raters be used and appropriately trained. 

  • Stolee (1999): GAS appears to be more realistic in settings where clinicians operate as a team, rather than on an individual basis; beneficial in settings where clinicians have direct control over the implementation of their clinical recommendations and treatment plans; improved length of stay for patients 

  • Turner-Stokes (2009): Setting objective goals using standardized wording can cut down on time to administer test. Weighting goals is recommended – this can be incorporated into the algorithm.

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Non-Specific Patient Population

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Test/Retest Reliability

Cytrnbaum (1979): r= .70 (3 wks. and 2 mos), r= .47 (2 mos. and 6 mos), r=.20 (3 wks. And 6 mos.) (Garwick,1974); r= .45 (for behavior change scale), r=.60 (for emotional change scale), r=.77 (for all scales) (McGagme and Menges, 1975)

Interrater/Intrarater Reliability

Psychogeriatric patients with cognitive disorders

  • Bouwens (2008): Rockwood et al. interrater reliability ICC=0.9, Stolee et al. interrater reliability ICC=0.9 and 0.9, Stolee et al. interrater reliability ICC=0.9 for change, 0.9 for discharge, r=0.9 for change, 0.9 for discharge

  • Cytrnbaum (1979): Inter-rater: r= .65 (total, first vs second interviewer), r=.61 (MSWs, first vs. second interviewer), r=.57 (RNS first vs second interviewer), r=.80 (RN first int., sec. int MSW), r=.59 (MSW first int., sec. int. RN), (Audette,1974); avg.=93 (range= .55 to 1.0 for 0-DTC), avg. =.95 (range =.55 to 1.0 for DTC II) (Austin, 1976); r = .71 (client vs. interviewer), r=.73 (client vs. interviewer), r=.51, r=.51, r=.85, (Garwick,1974), r= .71 (mean correlation sd=.23, range=.15-.95), Goodyear and Bitter, 1974; r= .52, (Jacobs and Cytrynbaum, 1977); Inter-rater score first to second interview: r= .704, inter-rater for intake guide: .711, inter-rater for therapist guide: .625 (Sherman et al., 1974) 

 

Nursing home patients

  • Gordon (1999): Excellent – ICC of 0.80

 

Cognitive rehabilitation patients

  • Rockwood (1997): Interrater reliability = 0.95 

 

 Patients with communication disorders

  • Schlosser (2004): Intrarater = 0.51-0.95 

Internal Consistency

Cytrnbaum (1979): Internal consistency indicators scales scores and overall GA score: .69; Internal consistency scale scores and total follow-up guide scores (by no. of scales): .98 (one scale), .78 (two scales), .68 (three scales), .66 (four scales), .64 (five scales), (Garwick,1974)

Construct Validity

Psychogeriatric patients with cognitive disorders

  • Bouwens (2008): Rockwood et al. Pearson correlations of change scores BI r=0.6, FIM r=0.5, MMSE r=0.0, KADL r=0.5, PSMS r=-0.5, IADL r=-0.4; Rockwood et al. Pearson correlations of change scores ADAS-Cog r=-0.5, GDS r=-0.5, CGI 4=-0.9, MMSE r=0.0, PSMS r=-0.3, IADL r=-0.4; Rockwood et al. MMSE, ADAS-Cog, PSMS, IADL, FAQ, CDS, CES-D, CIBIC-plus, patient/caregiver Spearman r=0.0 to 0.6, clinician Spearman r=0.0 to 0.8; Stolee et al. Pearson correlation of change scores BI r=0.9, GCOR r=0.8; Stolee et al Pearson correlation of change scores BI r=0.6, OARS IADL r=0.5, MMSE r=0.2, NHP r=0.0; follow up scores BI r=0.7, OARS IADL r=0.5, MMSE r=0.3, GCOR r=0.7, NHP r=-0.2; Yip et al. SMMSE Spearman r=0.1 BI, IADL, OARS IADL Spearman r between 0.4 and 0.5 

  • Cytrnbaum (1979): Concurrent validity: .63 (Pearson) of GA change score and total satisfaction score (p<.05), .92 of GA change score and GA score (p<.001), .67 of GA score and total satisfaction score (p<.02) (Carlson, 1974); 

  • GAS and Taylor Manifest Anxiety Scale at 2-month follow up= .52 (p<.05), though outcome measures excluding GAS highly inter-correlated over time (.73-.80) (Garwick, 1974b); 

  • GAS and Baxter Consumer Satsifaction Index (seven item) = .21 (N=686) and .23 (N=199) (Garwick, 1974b); 

  • GAS and Therapists Global Ratings (.58 -.85) (Garwick, 1974b); r=.24 for GA scores and “Relief” (p<.05) (three of 4 items highly intercorrelated r=.61, .59, .54 (p<.001)); r=.43 for GA scores and global ratings (p<.001); r=.63 for GA scores and type of discharge (p<.001); r=.45 for GA scores and LOS (p<.001) (Jacobs and Cytrynbaum, 1977); 

  • r=.43 (Spearman-rho) between program level GAS scores and patient ratings of program (NS); r=.16 between program level change scores (GAS) at pt. ratings (NS) Recalculated excluding activities led by staff member w/less GAS training, rose to .74 (p<.01) and .36 (NS) (Lefkowits, 1974); 

  • GAS and Mean change Index = .285; GAS and Mean change score =.306 (Mauger et al., 1974); Pearson r= .14 (Santa-Barbara et al., 1974); 

  • r=.49 for client GA rating and client satisfaction (p<.01); r=.28 for LOS and client GA rating (p<.05); r=.31 for goal specific adjustment (sub-scales of self-assessment guide) and client GA rating (p<.05) (Willer and Miller, 1976) 

 

Nursing home patients

  • Gordon (1999): Convergent: r = 0.15 with Barthel Index; r = 0.17 with HABAM. 

 

Patients with communication disorders

  • Schlosser (2004): compared to Health Sickness Rating scale: r = 0.71; target complaints scale: r = 0.50; brief symptom inventory: r = 0.38; Rosenberg Self-Esteem Scale: r = 0.34

Content Validity

Psychogeriatric patients with cognitive disorders

  • Bouwens (2008): Good - Rockwood et al. expert panel, Stolee et al. position statements, Stolee et al. expert panel, Yip et al. position statements 

 

Patients with communication disorders

  • Schlosser (2004): recommends content validity be assessed on a case-by-case basis 

Responsiveness

Psychogeriatric patients with cognitive disorders

  • Bouwens (2008): Hartman et al. t test=2.9 d.f.=9 p=.02 ES= 2.3 ANOVA=0.4, Rockwood et al. ES=4.9 RE=4.5, Rockwood et al. ES=0.6 RE=0.5, Rockwood et al. SRM caregiver=0.4/0.2 SRM clinician=0.4/0.4, Stolee et al. ES=3.5 SRM=1.7 RE=3.1 ANOVA=0.8, Yip et al. SRM=1.6 RE=3.2 

 

Nursing home patients

  • Gordon (1999): Good - effect size = 1.29; highest relative efficiency = 53.7 

Pediatric Disorders

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Minimal Detectable Change (MDC)

Pediatric rehabilitation – CP, movement

Steenbeek (2007): 7, (maximum score = 50; MDC = 10)

Interrater/Intrarater Reliability

Infants with motor delay (defined by PDMS) 

  • Palisano (1992): ICC = 1.00 

 

Infants, 4-24 months, with motor delay

  • Palasino (1993): kappa (behavioral) = 1.0; kappa (GAS) = 0.75 kappa; ICC = 0.96 for PDMS 

 

Pediatric rehabilitation – CP, movement

  • Steebeek (2007): Good – ICC of 0.89.

 

Children with cerebral palsy

  • Steenbeek (2010): Good/excellent interrater reliability – therapist kappa = 0.82; kappa for individual rater = 0.64, (Steenbeek, 2010) 

Criterion Validity (Predictive/Concurrent)

Pediatric rehabilitation – CP, movement

  • Steenbeek (2007): Low – r = 0.44 

 

Infants with motor delay (defined by PDMS)

  • Palisano (1992): Concurrent: compared to PDMS Gross Motor = 0.44; compared to PDMS Fine Motor = 0.18 

 

 Infants, 4-24 months, with motor delay

  • Palisano (1993): Concurrent to PDMS, Pearson’s r = 0.25 for months 1-3; Pearson’s r = 0.33 for moths 4-6.

Content Validity

 Infants, 4-24 months, with motor delay

  • Palasino (1993): 10 expert Pediatric PTs rated 10 randomly selected goals in each dimension of content validity, on a 5-point ordinal scale. They rated whether expected levels of goal attainment represented progress infants were capable of achieving; and, and whether these levels represented clinically important change. 

 

Pediatric rehabilitation – CP, movement disorders Gordon (1999): Nursing home patients; long-term geriatric care

  • Steenbeek (2007): Acceptable – 77-88% of physical therapist ratings met criterion of GAS.

Floor/Ceiling Effects

Pediatric rehabilitation – CP, movement disorders

  • Steenbeek (2007): avoided by using Likert coding 

 

Children with cerebral palsy

  • Steenbeek (2010): No floor, and improbable ceiling effects

Responsiveness

Infants with motor delay (defined by PDMS)

  • Palasino (1992): Excellent: GAS T-Score = 55.4; score of 50 indicates significant change 

 

Infants, 4-24 months, with motor delay

  • Palasino (1993): Excellent: GAS T-Score (months 1-3) = 53.0; (months 4-6) = 60.3; score of 50 indicates significant change 

Chronic Pain

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Interrater/Intrarater Reliability

Patients with chronic pain

  • Fischer (2002): Satisfactory

Floor/Ceiling Effects

Patients with chronic pain

  • Fischer (2002): -1 was scored as their current level of function to avoid floor effect 

Limb Loss and Amputation

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Interrater/Intrarater Reliability

Male and female lower extremity amputees between ages 72.3 years old +/- 10.7 years.

  • Rushton (2002): ICCs of .87 and .91 have been reported for GAS among the geriatric population. ICCs of .92 and .94 have been reported for GAS within brain injury populations. 

Construct Validity

Male and female lower extremity amputees between ages 72.3 years old +/- 10.7 years

  • Rushton (2002): Correlation scores between the GAS and the Barthel Index has ranged between r = .59 and .86 when used in geriatric care settings. 

  • Correlation between GAS and Barthel Index (postal version) in the population of lower extremity amputees was r =.44; and between GAS and LCI was r =.35. 

Floor/Ceiling Effects

Male and female lower extremity amputees between ages 72.3 years old +/- 10.7 years

  • Rushton (2002): If it was possible for patient status to deteriorate, subject’s current status was defined as -1, rather than defining baseline at -2, (to account for floor effect). 

Responsiveness

Male and female lower extremity amputees between ages 72.3 years old +/- 10.7 years

  • Rushton (2002): Effect size = 6.5

Cerebral Palsy

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Interrater/Intrarater Reliability

Children with cerebral palsy

  • Steenbeek (2010): Good/excellent interrater reliability – therapist kappa = 0.82; kappa for individual rater = 0.64, (Steenbeek, 2010) 

Floor/Ceiling Effects

Children with cerebral palsy

  • Steenbeek (2010): No floor, and improbable ceiling effects

Older Adults and Geriatric Care

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Interrater/Intrarater Reliability

Geriatric patient population

Stolee (1999): 

  • Excellent interrater reliability = 0.88-0.93

Responsiveness

Rural, frail, older adults

  • Rockwood (2003): GAS Self-care: Effect size = 2.93; standardized response mean = 1.07; relative efficiency >100; Norman’s responsiveness = 0.57; GAS Mobility: Effect size = 4.43; standardized response mean = 0.91; relative efficiency >100; Norman’s responsiveness = 0.32; GAS Incontinence: Effect size = 3.51; standardized response mean = 0.78; relative efficiency = 29.92; Norman’s responsiveness statistic = 0.34 

Bibliography

Bouwens, S. F., C. M. van Heugten, et al. (2008). "Review of goal attainment scaling as a useful outcome measure in psychogeriatric patients with cognitive disorders." Dement Geriatr Cogn Disord 26(6): 528-540.

Cytrynbaum, S., Y. Ginath, et al. (1979). "Goal attainment scaling a critical review." Evaluation Review 3(1): 5-40.

Fisher, K. and R. Hardie (2002). "Goal attainment scaling in evaluating a multidisciplinary pain management programme." Clinical Rehabilitation 16(8): 871-877.

Gordon, J. E., C. Powell, et al. (1999). "Goal attainment scaling as a measure of clinically important change in nursing-home patients." Age and Ageing 28(3): 275-281.

Palisano, R. J. (1993). "Validity of goal attainment scaling in infants with motor delays." Physical Therapy 73(10): 651-658.

Palisano, R. J., S. M. Haley, et al. (1992). "Goal attainment scaling as a measure of change in infants with motor delays." Physical Therapy 72(6): 432-437.

Rockwood, K., S. Howlett, et al. (2003). "Responsiveness of goal attainment scaling in a randomized controlled trial of comprehensive geriatric assessment." Journal of Clinical Epidemiology 56(8): 736-743.

Rockwood, K., B. Joyce, et al. (1997). "Use of goal attainment scaling in measuring clinically important change in cognitive rehabilitation patients." Journal of Clinical Epidemiology 50(5): 581-588.

Rockwood, K., P. Stolee, et al. (1993). "Use of goal attainment scaling in measuring clinically important change in the frail elderly." Journal of Clinical Epidemiology 46(10): 1113-1118.

Rushton, P. W. and W. C. Miller (2002). "Goal attainment scaling in the rehabilitation of patients with lower-extremity amputations: a pilot study." Archives of Physical Medicine and Rehabilitation 83(6): 771-775.

Schlosser, R. W. (2004). "Goal attainment scaling as a clinical measurement technique in communication disorders: A critical review." J Commun Disord 37(3): 217-239.

Steenbeek, D., M. Ketelaar, et al. (2007). "Goal attainment scaling in paediatric rehabilitation: A critical review of the literature." Developmental Medicine & Child Neurology 49(7): 550-556.

Steenbeek, D., M. Ketelaar, et al. (2010). "Interrater reliability of goal attainment scaling in rehabilitation of children with cerebral palsy." Arch Phys Med Rehabil 91(3): 429-435.

Stolee, P., Zaza, C., Pedlar, A., Myers, A. (1999). “Clinical Experience with Goal Attainment Scaling in Geriatric Care.” Journal of Aging and Health 11(6): 96-124.

Turner-Stokes, L. (2009). "Goal attainment scaling (GAS)  in rehabilitation: A practical guide." Clinical Rehabilitation 23(4): 362-370.

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