Patient-Specific Goal-Setting Method

Abstract

The Patient-Specific Goal-Setting Method (Dutch: Patiënt Specifieke Goal-setting methode; PSG) is an interactive, patient-centered clinimetric and clinical decision-making framework designed to operationalize collaborative goal construction, intervention planning, and longitudinal functional monitoring within physical therapy and rehabilitation sciences. Developed by Dr. Anita Stevens and colleagues at Zuyd University of Applied Sciences, the PSG represents a comprehensive paradigm shift and methodological enhancement of the traditional Patient-Specific Complaints instrument (Patiënt Specifieke Klachten, PSK), which was historically adapted from Stratford’s Patient-Specific Functional Scale (PSFS). Unlike static outcome measures that evaluate patient deficits in isolation, the PSG systematically integrates an idiographic assessment protocol into the iterative clinical reasoning cycle across four explicit phases: (1) functional problem clarification, (2) goal formulation, (3) collaborative treatment planning, and (4) outcome evaluation. Central to the PSG’s psychometric architecture is the deliberate reframing of the measurement continuum: the instrument transitions from a deficit-based scoring metric assessing “difficulty with execution” to an asset-based, positive health metric assessing the patient’s “ability to perform” (mogelijkheid tot uitvoeren) chosen activities on a 0 to 10 numerical rating scale (NRS), where higher scores denote superior functional capacity. Psychometric evaluations demonstrate high clinimetric responsiveness, substantial test-retest reliability ($ICC > 0.85$), and superior patient engagement characteristics compared to generic nomothetic indices. This article provides an exhaustive academic analysis of the PSG, delineating its theoretical foundation in Self-Determination Theory and Goal-Setting Theory, its clinimetric validation, administration architecture, and clinical implementation parameters.

Keywords

Patient-Specific Goal-Setting Method, PSG, goal setting, physical therapy, rehabilitation, shared decision-making, clinimetrics, Patient-Specific Functional Scale, Self-Determination Theory, positive health, functional capacity, outcome measurement

Authors

The Patient-Specific Goal-Setting Method was developed and standardized by Dr. Anita Stevens and colleagues within the Research Centre for Autonomy and Participation (Lectoraat Autonomie en Participatie) at Zuyd University of Applied Sciences (Zuyd Hogeschool) in Heerlen, the Netherlands, in collaborative alignment with rehabilitation clinicians, physical therapy specialists, and health services researchers across Dutch primary and secondary care networks.

• Primary Developer: Dr. Anita Stevens, PT, PhD — Senior Researcher, Research Centre for Autonomy and Participation, Faculty of Health, Zuyd University of Applied Sciences, Heerlen, The Netherlands.
• Collaborating Institutions: Zuyd University of Applied Sciences; Department of Family Medicine and Department of Rehabilitation Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
• Author Contact Information: Zuyd Hogeschool, Nieuw Eyckholt 300, 6419 DJ Heerlen, The Netherlands. Web: https://www.zuyd.nl.

Purpose

The primary clinical and psychometric purpose of the Patient-Specific Goal-Setting Method is to provide healthcare professionals—primarily physical therapists, occupational therapists, and rehabilitation specialists—with an evidence-based, structured, yet highly personalized instrument that embeds measurement directly into the clinical therapeutic alliance. Conventional standardized, nomothetic health-related quality of life (HRQoL) instruments (such as the SF-36, EuroQol-5D) and condition-specific questionnaires (e.g., the Oswestry Disability Index or the Western Ontario and McMaster Universities Osteoarthritis Index) rely on fixed inventories of functional activities. Although these fixed batteries provide standardized cross-sectional benchmarks, they routinely fail to capture idiosyncratic activities that are of critical, self-defining value to an individual patient’s daily life, vocational obligations, or recreational pursuits.

To address this clinical limitation, the PSG functions as an idiographic measurement system designed to achieve three foundational objectives:

• Facilitate Active Patient Agency: Traditional rehabilitation models position the patient as a passive recipient of diagnostics and prescriptive regimens. The PSG mandates active patient participation by guiding the patient through explicit, standardized steps that illuminate their personal activity restrictions, foster intrinsic motivation, and build mutual consensus regarding treatment targets.
• Operationalize Positive Health and Strengths-Based Framing: Departing from legacy instruments that gauge functional “burden,” “complaint severity,” or “difficulty,” the PSG explicitly measures the patient’s perceived ability or possibility to perform (mogelijkheid tot uitvoeren). This conceptual inverted scoring scale reinforces self-efficacy, aligns with modern frameworks of Positive Health, and removes cognitive dissonance during recovery by establishing that higher numbers mathematically indicate functional advancement.
• Seamless Methodological Integration: Rather than existing as an isolated, bureaucratic questionnaire administered solely at intake and discharge, the PSG functions as an interactive roadmap. It embeds two critical structural stages that were completely absent from its predecessor, the PSK: explicit collaborative goal formulation and structured treatment plan co-design.

Psychological Construct

The PSG measures individualized functional ability within meaningful life activities, conceptualized through an integrative biopsychosocial lens. Rather than treating physical function as a static biological variable, the construct measured by the PSG is inherently cognitive-behavioral and phenomenological: it evaluates an individual’s appraisal of their functional competence, perceived autonomy, and self-efficacy when engaging in self-selected everyday activities.

Core Dimensions and Clinical Phases

The construct is operationalized through a four-phase methodological process, each tapping into distinct psychological and functional sub-constructs:

• Phase 1: Problem Clarification (Perceived Activity Limitations): In this opening exploratory phase, the patient identifies specific physical activities and social participation domains that are disrupted by their health condition. This dimension captures the cognitive appraisal of functional limitation within the context of the patient’s unique physical, social, and occupational environment. Instead of choosing from predetermined checklists, the patient elicits idiographic priorities (e.g., “climbing the stairs while carrying my two-year-old grandchild” or “working at my computer workstation for 45 consecutive minutes without cervical pain”).
• Phase 2: Goal Setting (Autonomous Motivation and Action Planning): This newly added dimension translates identified activity limitations into concrete, achievable, and personally meaningful target outcomes. Grounded in intentional behavior change, this phase assesses the patient’s aspirational functional horizon, determining the precise behavioral thresholds required for successful recovery.
• Phase 3: Collaborative Treatment Planning (Shared Decision-Making and Working Alliance): This phase captures the structural agreement between clinician and patient regarding the therapeutic trajectory. It evaluates the concordance between physiological therapeutic possibilities and the patient’s personal value priorities, fostering a shared cognitive representation of the therapeutic pathway.
• Phase 4: Longitudinal Evaluation (Appraisal of Functional Ability): Evaluated on a 0-to-10 metric, this dimension measures the patient’s perceived functional execution capacity across the designated target activities over time. By tracking movement along the 11-point anchor continuum, the PSG measures the reconstruction of self-efficacy and the restoration of physical agency.

Theoretical Framework

The conceptual foundation of the Patient-Specific Goal-Setting Method rests on the intersection of four prominent behavioral and health sciences frameworks:

1. Self-Determination Theory (SDT)

According to Self-Determination Theory, human motivation and psychological well-being require the satisfaction of three fundamental psychological needs: autonomy (experiencing oneself as the author of one’s actions), competence (feeling effective in interacting with the social and physical environment), and relatedness (feeling connected to and understood by others). The PSG directly operationalizes SDT in clinical practice:

• Autonomy is nurtured by honoring the patient’s voice in determining which functional activities matter, rather than imposing standardized clinician-centric goals.
• Competence is reinforced by reframing the scoring metric toward current execution abilities and incrementally celebrating measurable gains on the 0-10 scale.
• Relatedness is forged via the egalitarian, transparent communication cycle that characterizes the four-step protocol.

2. Goal-Setting Theory

Developed by Edwin Locke and Gary Latham, Goal-Setting Theory posits that specific, challenging, yet attainable goals lead to higher task performance than vague “do your best” intentions or absent goal structures. The PSG incorporates structured goal-setting mechanisms that guide patients to formulate precise, time-delimited, and contextually anchored functional milestones, thereby channeling attentional focus, energizing effort, promoting persistence, and fostering strategic problem-solving during physical rehabilitation.

3. The International Classification of Functioning, Disability and Health (ICF)

The World Health Organization’s ICF framework delineates health across three distinct levels: Body Functions/Structures, Activities, and Participation. Traditional physical therapy historically focused on the impairment level (e.g., joint range of motion, muscle torque). The PSG deliberately shifts assessment upward to the Activities and Participation components, measuring functional interactions within real-world environments while accounting for personal and environmental contextual factors.

4. Shared Decision-Making (SDM) and Working Alliance

Modern clinical practice emphasizes shared decision-making as an ethical and clinical imperative. The PSG creates an explicit communication scaffold that mitigates power asymmetries between practitioner and patient. In doing so, it directly strengthens the therapeutic alliance—a construct repeatedly demonstrated to independently predict favorable treatment outcomes across chronic pain and musculoskeletal rehabilitation.

Validity

The validity of patient-specific measurement instruments, particularly descendants of the PSFS and PSK like the PSG, has been extensively substantiated within clinimetric and musculoskeletal health literature.

Content and Face Validity

Content and face validity represent the foremost psychometric strengths of the PSG. Because the items are elicited directly from the patient’s phenomenological experience of their condition, the instrument guarantees $100%$ contextual relevance to the patient. Qualitative investigations into the PSG demonstrate that both patients and healthcare providers report exceptionally high face validity; patients feel actively heard and acknowledge that the assessed items represent the quintessential struggles of their daily living, avoiding the irrelevant or ceiling-compromised items common to fixed questionnaires.

Construct and Convergent Validity

Construct validity for patient-specific measures has been investigated by correlating change scores on individualized functional activities with established, validated condition-specific and generic outcome instruments:

• Correlation with Disease-Specific Instruments: Across cohorts with low back pain, neck pain, and osteoarthritis, patient-specific functional scores demonstrate moderate-to-high correlations ($r = 0.55$ to $r = 0.78$) with validated functional scales such as the Oswestry Disability Index (ODI), the Roland-Morris Disability Questionnaire (RMDQ), and the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure.
• Divergent/Discriminant Validity: PSG scores exhibit significantly lower correlations ($r = 0.20$ to $r = 0.38$) with general psychological distress scales (e.g., HADS) and systemic vitality metrics, proving that the instrument selectively isolates physical functional ability rather than non-specific negative affectivity.

Longitudinal Construct Validity (Responsiveness)

Responsiveness—the ability to detect clinically meaningful change over time—is an area where patient-specific methods consistently outshine fixed nomothetic instruments. In empirical trials comparing the PSFS/PSK methodology against generic HRQoL tools (SF-36) and regional impairment tools, patient-specific measures demonstrated larger standardized effect sizes and standardized response means (SRMs often exceeding $1.20$ to $1.60$). Because the PSG tracks only those activities in which the patient experienced actual baseline impairment, it avoids the statistical dilution caused by unresponsive, irrelevant questions embedded in standard inventories.

Reliability

Despite the idiographic, non-standardized nature of the elicited activities, the clinimetric reliability of the underlying numerical rating scale and elicitation methodology has been rigorously documented.

Test-Retest Reliability

In stable patient populations assessed over intervals of 24 to 72 hours prior to therapeutic intervention, patient-specific functional measures exhibit high test-retest reliability. Intraclass Correlation Coefficients ($ICC_{\text{agreement}}$) across various musculoskeletal settings consistently fall between 0.82 and 0.94. When clinicians receive formal instructional training in the standardized four-step PSG protocol, measurement variance attributable to administrative discrepancy is substantially minimized, preserving exceptional temporal stability.

Measurement Error and Minimal Detectable Change

Clinimetric precision is fundamentally defined by the Standard Error of Measurement (SEM) and the Minimal Detectable Change (MDC):

• Standard Error of Measurement (SEM): The SEM for individual item scores on the 0-10 numerical scale generally ranges from $0.60$ to $1.10$ points. When taking the aggregate average of three to five selected activities, the SEM drops to approximately $0.45$ to $0.80$ points.
• Minimal Detectable Change at the 90% Confidence Level ($MDC_{90}$): For average scores across nominated activities, the $MDC_{90}$ is approximately 1.5 to 2.0 points on the 11-point scale. A change of $2.0$ points or greater can be stated with $>90%$ statistical certainty to represent true biological and functional progress beyond measurement noise.
• Minimal Important Change (MIC): Anchor-based clinical investigations using Global Perceived Effect (GPE) scales indicate that a change of 2.0 to 2.3 points on the PSG corresponds to a meaningful, patient-identified clinical recovery.

Factor Analysis

Because the Patient-Specific Goal-Setting Method is an idiographic, clinimetric measurement model rather than an invariant, nomothetic psychometric inventory, traditional confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) are applied differently than they are to instruments with fixed content.

Clinimetric vs. Psychometric Architecture

In traditional psychometrics (reflective models), items are assumed to be manifestations of a single, latent psychological trait (e.g., general anxiety or depressive affect). Under that paradigm, factor analysis seeks high inter-item correlation and invariant factor loadings ($λ$). Conversely, the PSG functions under a formative or clinimetric framework:

• The specific activities elicited (e.g., gardening, cycling, stair negotiation) do not necessarily correlate highly with one another, because a patient may regain the physical ability to cycle comfortably while still experiencing severe mechanical restriction during sustained overhead lifting.
• Therefore, high internal consistency (e.g., excessively high Cronbach’s alpha $> 0.90$) across diverse patient-specific activities is neither theoretically expected nor clinimetrically desirable, as redundant activities would restrict the clinical breadth of the evaluation.

Structural Evaluation via Item Response Theory and Rasch Modeling

Modern psychometric evaluations of patient-specific scales have utilized Rasch analysis and nonparametric Item Response Theory (IRT) to evaluate whether patient-generated items conform to a hierarchical continuum of functional difficulty. Rasch analyses confirm that when clinicians follow standardized elicitation instructions, the underlying rating scale (0 to 10) functions unidimensionally as an assessment of perceived functional capacity, exhibiting ordered response thresholds and absence of severe item-step disordering.

Instrument / Measurement Tool

The Patient-Specific Goal-Setting Method is administered through a structured, interactive clinical interview accompanied by standardized documentation forms. Below are the structural parameters of the instrument:

• Instrument Type: Interactive, clinimetric, patient-reported outcome and goal-setting system.
• Administration Format: Clinician-facilitated structured interview integrated into routine electronic health record (EHR) physical therapy documentation; paper-and-pencil or digital tablets.
• Target Population: Adults and older adults experiencing physical limitations, functional impairments, or participation restrictions associated with musculoskeletal, orthopaedic, or neuromuscular disorders.
• Number of Target Activities: Typically 3 to 5 self-selected functional activities elicited from the patient.
• Response Format: 11-point Numerical Rating Scale (NRS) ranging from 0 to 10:
  • Score 0: Completely unable to perform the activity (onmogelijk uit te voeren).
  • Score 10: Able to perform the activity completely without any problem (zonder enige moeite / probleem uit te voeren).
• Scoring Mechanism:
  • Individual Activity Score: Each selected activity receives an integer score from 0 to 10 at baseline ($T_0$), intermediate assessments ($T_1$), and discharge ($T_2$).
  • Composite Mean Score: The sum of the scores of all nominated activities divided by the number of nominated activities:
    $$\text{PSG Composite Score} = \frac{\sum_{i=1}^{k} \text{Score}_i}{k}$$
    where $k$ is the total number of patient-selected functional activities (typically $3 le k le 5$).
  • Directionality: Higher scores reflect greater functional independence, physical capacity, and goal achievement. Positive change scores ($\Delta = T_{\text{final}} – T_{\text{baseline}}$) denote clinical improvement.
• The Four Stepwise Methodological Steps:
  1. Step 1 — Clarification of Health Problems: Collaborative interview to inventory and prioritize activity-related functional restrictions.
  2. Step 2 — Goal Formulation: Transforming prioritized functional limitations into concrete, time-framed functional goals.
  3. Step 3 — Collaborative Treatment Planning: Jointly structuring therapeutic modalities, behavioral changes, and clinical expectations into an agreed plan.
  4. Step 4 — Structured Evaluation: Periodic re-assessment of each activity using the 0-10 numerical scale to evaluate progress and adapt therapy accordingly.

Permissions & Fee and Test Year

The Patient-Specific Goal-Setting Method was finalized and published in its comprehensive standardized format in 2017 by Dr. Anita Stevens through Zuyd University of Applied Sciences (Zuyd Hogeschool). The underlying development of the instrument emerged from multi-year implementation studies evaluating the integration of goal-setting protocols within Dutch physical therapy practice.

• Fee and Availability: The clinical documentation forms, manual (Handleiding), and explanatory guides (Toelichtingsformulier) are made available as open-access clinical resources for healthcare practitioners and academic researchers. There is no royalty or licensing fee required for non-commercial clinical or academic research use.
• Professional Training Requirements: As emphasized by the developers, while the instrument forms are accessible, formal training or educational instruction (scholingsmodule) is strongly recommended to ensure that physical therapists properly apply the cyclical communicative steps rather than reducing the PSG to a superficial scoring rubric.
• Official Repository: Access to the official manual, forms, and clinical toolkits is hosted by the Research Centre for Autonomy and Participation at Zuyd University: Zuyd University PSG Portal.

References

• Beurskens, A. J., de Vet, H. C., Koke, A. J., van der Heijden, G. J., & Knipschild, P. G. (1996). Measuring the functional status of patients with low back pain: Assessment of the quality of four disease-specific questionnaires. Spine, 21(15), 1769–1775. https://doi.org/10.1097/00007632-199608010-00011
• Deci, E. L., & Ryan, R. M. (2000). The “what” and “why” of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11(4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01
• Locke, E. A., & Latham, G. P. (2002). Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. American Psychologist, 57(9), 705–717. https://doi.org/10.1037/0003-066X.57.9.705
• Stevens, A. (2017). Patiënt Specifieke Goal-setting methode (PSG): Handleiding en toelichtingsformulier voor het fysiotherapeutisch methodisch handelen. Zuyd Hogeschool, Lectoraat Autonomie en Participatie. https://www.zuyd.nl/onderzoek/lectoraten/projecten-autonomie-en-participatie/producten-en-diensten/psg
• Stevens, A., Beurskens, A., Koke, A., & van der Weijden, T. (2013). The use of patient-specific measurement instruments in physical therapy: What do we know about goal setting? A systematic review. Disability and Rehabilitation, 35(15), 1229–1239. https://doi.org/10.3109/09638288.2012.726315
• Stratford, P., Gill, C., Westaway, M., & Binkley, J. (1995). Assessing disability and change on individual patients: A report of a patient-specific measure. Physiotherapy Canada, 47(4), 258–263. https://doi.org/10.3138/ptc.47.4.258
• World Health Organization. (2001). International Classification of Functioning, Disability and Health: ICF. World Health Organization. https://apps.who.int/iris/handle/10665/42407

Items of the Scale