Longitudinal effects of time since injury and age at injury on outcomes of people with spinal cord injury in Queensland, Australia.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: To investigate the longitudinal effects of time since injury and age at injury on outcomes of quality of life, physical function, secondary conditions and participation, in people with traumatic spinal cord injury (SCI). SETTING: Community resident people with spinal cord injury in Queensland, Australia. METHODS: A baseline sample of 270 people with SCI was recruited. Telephone surveys on measures of quality of life (WHOQOL-Bref), secondary conditions (Secondary Conditions Surveillance Instrument, subset), physical functioning (Functional Independence Measure motor subscale) and participation (Community Integration Measure) were conducted each year between 2004 and 2008, and again in 2018. Random-effect within-between models were used to determine the effect of time since injury and age at injury on each outcome variable. Inverse probability-of-censoring weights were used to correct for selection bias. RESULTS: There was an effect of time since injury on secondary conditions, with a one-year change associated with 9% higher odds of having worse Secondary Conditions Surveillance Instrument scores (odds ratio = 1.09, 95% confidence interval = 1.02, 1.17; p = 0.006). We did not find any evidence of a time since injury effect on quality of life, physical function, or participation. Similarly, we did not find any evidence of an age at injury effect on any outcome variable. CONCLUSIONS: Secondary conditions may increase with longer time since injury among people with SCI, suggesting appropriate formal and informal supports are required to minimise the impact of these emerging health problems as individuals age.

Impact of voice and communication deficits for individuals with cervical spinal cord injury living in the community.

BACKGROUND: Post-spinal cord injury (SCI), individuals may exhibit mild to moderate impairments in aspects of speech influenced by impaired respiratory support. However, limited research has been conducted into the impact of these impairments on activity and participation when living in the community. AIMS: To examine the nature and extent of voice and communication function in a group of individuals with cervical SCI living in the community, and to explore participant perceptions of the impact of these deficits on levels of activity and participation. METHODS & PROCEDURES: Participants included 14 individuals who had sustained a SCI above C8 level and had returned to living in the community. All completed a series of speech and voice assessments, the Voice Handicap Index, the Australian Therapy Outcome Measures Voice scale, four voice perception questions, and the General Short Form of the Communicative Participation Item Bank. OUTCOMES & RESULTS: As a group, participants were found to have reduced vocal intensity and phonatory duration. Vocal quality was mildly altered in 93% and pitch control, breath support for speech, speech rate and phrase length impacted in one-quarter or more of the group. All reported impacts, though three individuals reported that their impairments had more extensive impact on communication in daily life. CONCLUSIONS & IMPLICATIONS: Individuals post-SCI experience mild speech and voice deficits that can have negative impacts on functional communication. The monitoring of communication function may help to identify those individuals who could benefit from additional support and intervention on return to community life.

General practice visits by people with traumatic spinal cord injury: a Queensland longitudinal study.

People with traumatic spinal cord injury (SCI), although proportionally fewer in number, are known to be high users of primary health care services; however, details of their visits to GPs are unclear. This study presents information about GP utilisation patterns of 193 people with SCI over a 5-year period. Results demonstrate substantially greater GP service utilisation, particularly for young men with SCI, compared with their counterparts in the general population. Interestingly, people with paraplegia were proportionally higher users of GP services than those with tetraplegia. Results indicate the need for specialist support for GPs to meet the SCI-specific needs of this patient group. Specialist SCI outreach teams may be a useful resource to primary health care practitioners.

Disability Research in Australia: Deciding to Be a Research Participant and the Experience of Participation.

Little is known about why people with disability choose to take part in disability research and what their experience is like. Knowledge of this may help researchers and research ethics committees improve the empowered and ethical participation of people with disability in disability, healthcare, and human service focussed research. This cross-sectional mixed-methods study explored the perspectives and experiences of a group of Australian adults with disability regarding their involvement in research. Online surveys (N = 29) and follow-up interviews (N = 15) were conducted. The study found the decision to participate was a complex appraisal of benefit to self and others, research relevance, value, comfort, convenience, safety and risk. The attitudes and behaviours of researchers in cultivating trust by adopting an empathic approach to the conduct of disability research appear to be an important aspect of participant experience. Research ethics committees may benefit from knowledge of the 'microethical' moments that occur in such research.

Investigating changes in quality of life and function along the lifespan for people with spinal cord injury.

OBJECTIVE: To track changes in quality of life and function for people with spinal cord injury (SCI) along the lifespan. DESIGN: A wave panel design in which data were collected annually over 5 years across 6 strata that represented different periods since injury. SETTING: Telephone interviews with participants in their home environment. PARTICIPANTS: People (n=270) who had sustained a traumatic SCI in Queensland, Australia, over the previous 60 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Quality of life was measured using the World Health Organization Quality of Life-8. Human functioning was measured in 3 components. Body structure/function was measured using the Secondary Conditions Surveillance Instrument. Activity was measured using the motor subscale of the FIM (mFIM) and the Clinical Outcomes Variables Scale. Participation was measured using the Community Integration Measure (CIM) and the Impact on Participation and Autonomy questionnaire. RESULTS: Quality of life remained relatively constant across the lifespan. For body structure/function, there was a significant increase in secondary conditions with time since injury. There was a significant decrease in activity as measured by the mFIM for higher functioning individuals. Participation, as measured by the CIM, showed a significant increase with time since injury, but not when adjusted for the American Spinal Injury Association Impairment Scale, income level, and living situation. CONCLUSIONS: The findings of this study highlight that people with SCI are able to maintain quality of life and participation along the lifespan; however, increases in secondary conditions and a decline in function over time are likely. Rehabilitation services could work more effectively at addressing secondary prevention through enhanced monitoring over time, while broader societal responses are likely to hold the key to optimizing human functioning.

Influences on Participation in Life After Spinal Cord Injury: Qualitative Inquiry Reveals Interaction of Context and Moderators.

Background: Greater understanding of the influences on participation in life after spinal cord injury (SCI) can inform rehabilitation theory and practice. Careful qualitative inquiry can reveal subjective meanings associated with the relevant experiences, strategies, and perceptions of those with lived experience of SCI. A search of literature, followed by a thematic synthesis of qualitative studies, was undertaken to bring together these insights in a meaningful way. Methods: The research question guiding the literature review and synthesis was, What do people with SCI perceive to be the influences on their participation in life? Three critical databases were searched for qualitative studies examining influences on participation in life after SCI. Peer-reviewed studies published after 2006, involving adults with SCI living in countries with advanced economies, were included. Data were extracted from 24 articles and subjected to three-level thematic synthesis-the coding of primary data from the studies, the development of descriptive themes based on an organization of those codes, and the generation of analytical themes. Results: The synthesis yielded five analytical themes, supported by 17 descriptive themes. The analytical themes were (1) external contextual influences, (2) personal physical context, (3) personal psychological context, (4) potential moderators of participation outcomes, and (5) temporal dimensions of participating in life after SCI. Interpretation: These themes highlight the complex interactions that shape participation from the perspective of people with SCI. Closer examination of the potential moderators may provide insights into effective rehabilitation interventions. Conclusions: Synthesis of qualitative inquiry provides valuable insights into the perceptions of influences on participation in life from the point of view of people with SCI. The findings of this synthesis are instructive for rehabilitation theory and practice. It can complement what we learn from using the ICF to understand participation.

Evaluating new roles for the support workforce in community rehabilitation settings in Queensland.

INTRODUCTION: Alternative workforce models need to be explored to adequately meet the future health care needs of the Australian population. A new role for the support workforce, to optimise their contribution in community rehabilitation in Queensland--the advanced community rehabilitation assistant (ACRA)--was developed on the basis of service activity mapping and gap analysis. OBJECTIVES: Evaluation of a trial of the new ACRA role at six pilot sites in Queensland. PARTICIPANTS: ACRAs, health professionals and rehabilitation clients. METHODS: Transcripts of semistructured telephone interviews conducted with ACRAs, health professionals and rehabilitation clients were thematically analysed. The nature of the role as well as perceived strengths and weaknesses were explored. RESULTS: The presence of an ACRA was generally seen to diversify and expand local service capacity. The major challenge was the initial intensity of instruction that was required from supervising health professionals. CONCLUSIONS: ACRAs have potential to be valuable resources in the provision of community rehabilitation services. The challenge of meeting each new ACRA's preliminary training needs requires further consideration. A critical mass of people trained to this role may be required to ensure sustainability. Further trial and evaluation is needed to investigate the role more thoroughly over time and in different settings.

Rehabilitation for participation in life after spinal cord injury - clinician responses to a preliminary conceptual framework.

PURPOSE: To explore face validity of a preliminary conceptual framework for rehabilitation (the HEAR Framework), which is grounded in the narratives of people with spinal cord injury. METHODS: Using a quantitative online survey, experienced spinal cord injury rehabilitation practitioners were asked to compare the overall Framework, and its three components and nine elements, against usual practice. Participants rated the helpfulness and ease of implementation of each component. Perceived training needs, to support the implementation of the Framework were also explored. Respondents were given the opportunity to provide qualitative feedback about the Framework. RESULTS: Thirty-four participants completed the survey. Median rating of congruence of the Framework with usual practice was 6 (out of 10). The Help component of the Framework was rated as more like usual practice than the Encourage and Accept components. Median rating of the potential helpfulness to practice, of all the elements of the Framework was 5 (out of 5). Participants rated the elements within the Help component of the Framework as easiest to implement. Teaching assertiveness, promoting flexible thinking and fostering responsive communication were the highest rated training topics related to implementation of the Framework. CONCLUSIONS: Face validity testing suggests the preliminary HEAR Framework is promising as a basis for spinal cord injury rehabilitation theory. Broad-based testing is required to progress the promise of the Framework.IMPLICATIONS FOR REHABILITATIONSpinal cord injury rehabilitation lacks conceptual frameworks to guide practice.This validity study suggests moderate alignment between the preliminary HEAR Framework and usual practice (based on the perceptions of professionals in a spinal cord injury service).The Framework may be useful to individual rehabilitation practitioners as a basis for clinical reflection.The Framework may be useful as a practice development tool for teams of rehabilitation practitioners.

Development of a participatory process to address fragmented application of outcome measurement for rehabilitation in community settings.

PURPOSE: Outcome measurement is an integral part of delivering rehabilitation services in community settings. However, measurement is of little value if instruments are chosen ad hoc and are not administered consistently. The purpose of this study was to develop and test a participatory process of outcome measure selection which would engender consistent use of robust and appropriate instruments. METHOD: The ICF provided the conceptual framework for a systematic review of the literature for relevant outcome measures. A summary of the critical appraisal of the clinimetric properties of the identified instruments was created. The summaries were reviewed and vetted by stakeholders including clinicians, researchers, and managers/policy makers. RESULTS: From the 300 identified and appraised measures, 28 were chosen and made available in a Compendium of Clinical Measures for Community Rehabilitation. The Compendium contains three core measures to be used routinely with all rehabilitation clients and a further 25 that cover particular discipline and client needs. This resource is now available to all clinicians working in the participating rehabilitation services. CONCLUSION: A participatory process combining rigorous review of the literature, expert opinion, and clinician feedback is recommended in the selection and implementation of outcome measures in rehabilitation settings in the community.

Experiences of communication changes following spinal cord injury: a qualitative analysis.

Purpose: Voice and communication changes can occur following cervical spinal cord injury due to dysfunction of the respiratory and phonatory subsystems. Few studies have explored the "lived experience" of communication changes post cervical spinal cord injury. Furthermore, the impacts of these changes on community activity/participation and requirements for psychosocial adjustment have not been well-elucidated. The current study explored the experience of communication changes in non-ventilated individuals following cervical spinal cord injury, using a biopsychosocial framework.Materials and Methods: Semi-structured interviews were conducted with 14 community-dwelling non-ventilated individuals with cervical spinal cord injury. Thematic analysis was undertaken using an inductive approach. Themes were subsequently coded against domains of the World Health Organization International Classification of Functioning Disability and Health model, using established linking rules.Results: Four main themes were identified: (1) how communication has changed; (2) difficulties getting the message across, (3) the multifactorial impact of communication changes on everyday life; and (4) strategies/support to adjust to communication changes. Communication changes had multifaceted effects on participants' functioning, and were represented equally across the Body Functions (12 codes), Activities/Participation (12 codes), and Environmental Factors (11 codes) domains of the model.Conclusions: Individuals with cervical spinal cord injury perceive and experience meaningful changes on communication function post-injury, with salient impacts to daily-living and social participation.IMPLICATIONS FOR REHABILITATIONAs a result of communication changes post-injury, individuals with cervical spinal cord injury experience several challenges across a variety of domains in daily lifeThe current study highlights the benefit of using a biopsychosocial framework, such as The International Classification of Functioning, Disability and Health (ICF), to consider the complex and diverse impact of communication changes on the functioning of individuals with cervical spinal cord injury, as well as the influence of environmental factors, on rehabilitation planningThe current data demonstrates the need for increased involvement of speech-language pathologists as core members of the multidisciplinary team, and for acute awareness by all health professionals of the potential impact of communication changes on rehabilitation and psychosocial adjustment in individuals with cervical spinal cord injury.

Smart-device environmental control systems: experiences of people with cervical spinal cord injuries.

BACKGROUND: Environmental control systems (ECS) are devices that enable people with severe physical limitations to independently control household appliances. Recent advancements in the area of environmental control technology have led to the development of ECS that can be controlled through mainstream smart-devices. There is limited research on ECS within Australia and no known research addressing smart-device ECS. The current study sought to explore users' experiences with smart-device ECS within Australia. METHODS: The study followed a single embedded case study method. Participants (n = 5) were existing ECS users with a cervical spinal cord injury. Data were collected through semi-structured interviews with participants, reflexive journals and field notes. An inductive approach was used to analyze the data thematically. RESULTS AND CONCLUSIONS: The experience of using a smart-device ECS presented both opportunities and costs to users. The opportunities included: independent control, choice, peace of mind, connection, effective resource use, and control over smart-phone functions and applications. The associated costs included: financial, time, frustration, and technical limitations. While findings are similar to previous research into traditional ECS this study indicates that smart-device ECS also offered a new opportunity for users to access mainstream smart-device functions and applications. Future research should investigate methods and resources that practitioners could utilize to better support new users of smart-device ECS. Implications for Rehabilitation As with traditional environmental control systems, users of smart environmental control systems report increased independence, choice and control. Smart-device environmental control systems provide users with access to mainstream smart-device functions and applications, which facilitate connection to family and the outside world. The costs to the user of smart-device environmental control systems include monetary and time investment, dealing with technical limitations and resulting frustration. Prescribers and installers must consider ways to mitigate these costs experienced by users.

Determinants of participating in life after spinal cord injury - advice for health professionals arising from an examination of shared narratives.

PURPOSE: To explore the perceived determinants of participation in life after spinal cord injury and incorporate these into a framework for the promotion of participation suitable for use by rehabilitation professionals. METHOD: Four people with spinal cord injury and one health service researcher engaged in a process of sharing narratives of life after spinal cord injury over a period of one year. The narratives were distilled using thematic analysis. RESULTS: The relevant subset of data from the narratives categorized as This is what we think determines our participation in life was analyzed in depth to reveal nine themes (1) The world can be my friend or foe; (2) I am who I am; (3) It is a personal journey; (4) Some like to talk, others like to do; (5) We have the technology; (6) A support network is vital and it can be built; (7) Life involves tradeoffs; (8) Push; and (9) Be flexible. These themes were combined into a framework for the promotion of participation to be used by rehabilitation professionals. The collaboratively developed framework has three aspects - Help me, Encourage me and Accept. CONCLUSION: The proposed participation promotion framework is grounded in the narratives of the research group but needs to be tested before it can be endorsed for practice. Implications for Rehabilitation In order to promote participation in life after spinal cord injury rehabilitation professionals can help people with spinal cord injury to negotiate the world, build and maintain a support crew and access equipment and technology. Spinal cord injury rehabilitation professionals can encourage people with spinal cord injury to push themselves, be assertive and be flexible, as these attributes can assist participation in life after spinal cord injury. In the pursuit of participation goals, rehabilitation professionals must accept the individuality of each person with spinal cord injury, respect that they may or may not be willing to make tradeoffs to achieve participation goals and that they are on an ever changing life journey.

Environmental control systems - the experiences of people with spinal cord injury and the implications for prescribers.

PURPOSE: Environmental control systems (ECSs) can potentially influence comfort, safety, security and independence for people with severe impairment from spinal cord injury (SCI). This study, aimed at informing prescription practises, investigated ECS prescription and utilisation from the consumer perspective. METHODS: Qualitative inquiry, through 15 semi-structured interviews, explored the perspectives of people with high level SCI who use ECSs. Data were coded and clustered to provide a description of their perspectives and interpret lessons for prescribers. RESULTS: The data were grouped into six coding clusters related to readiness to engage, training, autonomy, utility, utilisation and attitudes towards the ECS. Data revealed variability in readiness to embrace ECSs during rehabilitation, some frustration related to setting up systems and instances of ECSs not being used to their full potential. Some highly motivated participants found reward through perseverance. All participants valued having some level of autonomy and personal security. Significant implications for prescribers are described. CONCLUSIONS: Understanding the influence of factors related to devices, personal characteristics and individual context on ECS usage can guide clinicians in prescription and training processes to facilitate maximum and ongoing benefit from ECSs. A culture of follow-up and evaluation is to be encouraged. Implications for Rehabilitation A variety of factors may influence whether a person with severe impairment from spinal cord injury fully utilises and persists with using an environmental control system (ECS). Findings from this study illustrate the importance of client readiness for prescription and the influence of client perceptions of value, convenience and aesthetics on ECS use. Prescribers should seek to understand what each client needs to become engaged and proficient with ECS use. Prescribers should be knowledgeable about suggested ECSs. Prescribers should prepare clients for potential difficulties in establishing reliable ECS use and establish support mechanisms to facilitate perseverance until effective ECS use is established.

The consequences of increasing age and duration of injury upon the wheelchair posture of men with tetraplegia.

It has been suggested that postural problems experienced by people with spinal cord injury may increase with greater age and duration of injury; however, there has been little documentation of the magnitude of changes and their time course. Our study was conducted to measure the wheelchair posture of 30 participants with long and short duration of tetraplegia due to spinal cord injury as compared to 30 age-matched able-bodied participants. Posture measurements were derived from the relationships of bony landmarks which were recorded by photography. Results suggest that increasing age and duration of spinal cord injury are associated with more extreme pelvic angle and forward head posture. Thoracic kyphosis, as indicated by chest angle, was the main postural distinction between participants with tetraplegia and able-bodied participants. The kyphosis was not significantly greater in those with longer duration injury. Proactive intervention to prevent late onset postural problems is recommended.

Factors Which Facilitate or Impede Interpersonal Interactions and Relationships after Spinal Cord Injury: A Scoping Review with Suggestions for Rehabilitation.

Interpersonal interactions and relationships can influence an individual's perceptions of health and quality of life in the presence of disability. In the case of people with spinal cord injury (SCI), positive interpersonal interactions and relationships have been shown to contribute to resilience and adaptability. Understanding factors which facilitate or impede the development and maintenance of relationships after SCI may form the basis for proactive relationship support for people with SCI. To gain a broad insight into these factors, a scoping review was undertaken. Databases were searched for English language studies published between 2000 and 2015 that informed the review question. Sixty-two (62) studies were identified. Thematic analysis was conducted on data extracted from the studies and 51 factors which may facilitate relationships and 38 factors which may impede relationships after SCI were noted. The majority of factors could be categorized as environmental or personal according to the domains of the International Classification of Functioning, Disability, and Health (ICF). The facilitating factors included partner and social support, reciprocity in relationships, and presenting oneself positively. Impeding factors included physical environmental barriers, real and perceived social biases, and poor self-image. Factors identified may inform the provision of supportive, holistic rehabilitation for people with SCI.

Long duration spinal cord injury: perceptions of functional change over time.

PURPOSE: To investigate perceptions of functional change over time held by individuals with long duration spinal cord injury (SCI) living in Queensland, Australia. METHOD: A retrospective telephone questionnaire was administered to 84 individuals who had sustained a SCI more than 20 years previously and were older than 15 at the time of injury. Motor subset scores of the Functional Independence Measure (FIM) and a single scale measuring mobility aids status (MAIDS), were collected for three points in time--post discharge from initial rehabilitation (D/C point); approximately 10 years post injury (Mid point) and currently (Current point). RESULTS: A significant number of participants perceived that their function had increased between the D/C and Mid points and had subsequently decreased between the Mid and Current points. Participants also reported an increasing dependence on mobility aids between the Mid point and the Current point. Those who reported functional decline between the Mid and Current points were significantly older than those who did not report functional decline but did not differ in duration of injury or age at onset. CONCLUSIONS: The results support the need for services that provide assessment and intervention for functional changes throughout the life span of people with SCI.

Reducing inpatient hospital usage for management of pressure sores after spinal cord lesions.

Recurrent pressure sores are a devastating complication for people with spinal cord lesions as well as posing a drain on health resources. A programme of community outreach involving the long-term follow-up of people post-hospitalisation for severe pressure sores has been developed in Queensland, Australia. This service is known as SPOT (Spinal Outreach Team). The primary objective of this follow-up is to prevent recurrence of pressure sores where possible or alternatively to detect problems early so that rehospitalisation is avoided. In order to assess the effectiveness of this programme the readmission patterns of 14 patients with recurrent pressure sores were examined. The mean number of hospitalised days per patient per month were examined between 1991 and 2001. Three phases within this time frame were examined 1991-1995, no SPOT service; 1996-1998, generic SPOT service (without individual interventions) and 1999-January 2002, individualised SPOT programmes for high users. Hospital days per patient per month were significantly lower for the individualised phase than for the other two phases combined. Proactive, individually tailored approaches are recommended for individuals at high risk of readmission for pressure sores.

Descriptions of community by people with spinal cord injuries: concepts to inform community integration and community rehabilitation.

Effective measurement and optimization of re-entry into the community after injury depends on a degree of understanding of how those injured persons actually perceive their community. In light of the limited research about foundational concepts regarding community integration after spinal cord injury, this study investigated how a large number of adults with spinal cord injury described their local communities. In the course of telephonic interviews, qualitative descriptions of community were obtained from 269 participants (1-56 years postinjury). These were thematically analysed for content and valence by three researchers. In addition to descriptions of community as 'place', findings echoed the three dimensions commonly included in measures of community integration, namely social integration, occupation and independent living. Participants who described their community in social and relationship terms reflected generally positive views about that community, whereas those who described their community in terms of physical space and access expressed a relatively greater proportion of negative views when describing their community. In general, substantial diversity of responses across participants suggested a need for greater complexity in understanding, measurement and clinical application of the notion of community within the area of community integration and participation. Specifically, the importance of focusing on social and relationship dimensions of community integration is emphasized for rehabilitation practice.

Reliability of the clinical outcome variables scale when administered via telephone to assess mobility in people with spinal cord injury.

OBJECTIVE: To examine the equivalence reliability and test-retest reliability of the Clinical Outcome Variables Scale (COVS) when administered via telephone (TCOVS) to people with spinal cord injury (SCI). DESIGN: Equivalence (telephone administration vs in-person) and test-retest reliability study. SETTING: Assessments conducted in participants' home environment. PARTICIPANTS: Equivalence reliability was examined in a convenience sample of 37 people with a diagnosis of traumatic SCI who had been discharged from the Queensland Spinal Injuries Unit to the community. In a separate group of participants, test-retest reliability of COVS when administered via telephone was examined in 43 people with SCI who were randomly selected from the Queensland Spinal Cord Injuries Service records. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Reliability was assessed at the subscale and composite score level using intraclass correlation coefficients (ICC(2,1)) and Bland-Altman limits of agreement. RESULTS: Reliability was good for TCOVS and COVS for the composite score (ICC=.98), mobility subscale (ICC=.97), and ambulation subscale (ICC=.99). Reliability was also good for TCOVS test and retest assessments for the composite score (ICC=1), mobility subscale (ICC=1), and ambulation subscale (ICC=1). For all comparisons, most data points were within the 95% limits of agreement and the width of limits of agreement were considered to be clinically acceptable. CONCLUSIONS: The study findings confirm the equivalence and test-retest reliability of the TCOVS in an SCI population when administered by trained raters.

Goal attainment scaling: an effective outcome measure for rural and remote health services.

The aim of this paper is to demonstrate the utility of Goal Attainment Scaling (GAS) as an effective, multidisciplinary measure of client outcomes for rural and remote health services. Goal Attainment Scaling was adopted by the Spinal Outreach Team (SPOT) as a client-focussed evaluation tool, as it is sensitive to the individual nature of clients' presenting issues and the multidisciplinary focus of the team. It enables individualised goals to be set on a five-point scale. Goal Attainment Scaling was introduced to the SPOT service after a pilot trial established guidelines for its effective implementation. An ongoing review process ensures that goal scaling remains realistic and relevant. Service outcomes can be effectively summarised using a frequency distribution of GAS scores. One of the important benefits of GAS is its facilitation of collaborative goal setting between clinician and client. Goal Attainment Scaling is recommended to rural and remote multidisciplinary health services because of its ability to summarise outcomes from heterogeneous service activities.