3.2.3. Indicators of Goal Attainment

The "expert model" included age, gender, injury severity, and total RPQ-score. The model showed an R<sup>2</sup> = 0.128, F (5, 49) = 1.439, *p* = 0.227. Controlling for baseline levels gave an R2 change of 0.055 and a non-significant F change (*p* = 0.085).


**Table 3.** SMART goal categories and goal attainment at final session.

Number of participants with goal within each category is given in the left column. Goal attainment levels at session 8 are given as "below expectation" (score −2 or −1), "at expectation" (score 0), and "above expectation" (score +1 and +2). The total number of goals per domain/category registered at each level of attainment are given in *n* (%).

As the model showed low predictive value, i.e., only predicted 12.8% of the total variance, univariate regression models were run to determine which explanatory variables should be included in the exploratory model. Results are presented in Table 4.

The final exploratory model of factors with a significance level <0.2 thus included gender, anxiety symptoms, self-reported executive function (BRIEF-A GEC t-score), and treatment expectation at session 3 and GAS baseline levels. This model showed R2 of 0.322, F (5, 52) = 4.854, *p* = 0.001. The R2 change was 0.116, F change significance was *p* = 0.005, i.e., the adjusted model showed complete case (Table 4), and imputed models (data not shown) showed similar results.

**Table 4.** Univariate regression analyses of goal attainment at final session (*n* = 59).


*Italics display results at acceptable p-value (<0.20) to be carried forward.* BRIEF-A = Behavioral Rating Inventory of Executive Functioning-Adult version. GAD-7 = Generalized Anxiety Disorder 7-items, GCS = Glasgow Coma Scale, GEC = Global Executive Composite, GOSE = Glasgow Outcome Scale Extended, PHQ-9 = Patient Health Questionnaire 9-item, RPQ = Rivermead Post-Concussion Questionnaire.

#### **4. Discussion**

This study aimed at describing goal attainment in patients receiving an individually tailored, home-based rehabilitation intervention and at describing goal attainment in different goal domains. We also explored indicators of goal attainment at the final session.

Goal attainment was very high. All participants had a positive total goal attainment change score, which means that all participants improved on at least one of their goals. The high levels of goal attainment found across patients with different injury severity, time since injury, current level of functioning, and different goal domains indicated that the intervention format is well suited for many individuals in the chronic phase of TBI. We believe that the high level of patient involvement in this study might have resulted in the high goal attainment seen, as suggested in the literature [74]. Additionally, setting goals and GAS has been shown to be effective in and of itself [75], which may have contributed to the results. Goals were categorized as related to either cognitive, physical/somatic, emotional, or social functioning. The level of goal attainment was equal across goal domains, which implies that the intervention was sufficiently tailored to allow participants to work effectively on a broad range of issues.

During baseline assessment in the RCT, patients and family members nominated target problem areas relating to TBI. A previously published paper [62] describes domains and categories of these problem areas. The problem areas reported at baseline were highly similar to the SMART goal areas reported in the current paper. A few problem areas reported at baseline were, however, not developed into SMART goals, i.e., visuospatial difficulties, reduced processing speed, difficulties with sensations, and difficulties with natural functions. Furthermore, some goal areas were not frequently established, such as goals related to identity difficulties and behavioral dysregulation. This may suggest that some problem areas are less easy to translate to SMART goals. If this was the result of difficulties in operationalizing abstract goal themes when applying GAS, this implies some limitation to the use of GAS. However, it might also be that abstract themes such as impaired self-awareness and identity difficulties were addressed while working on more concrete, everyday activities nominated by the patients, e.g., increased social activity.

The initial investigation of indicators of goal attainment based on theoretical, empirical, and clinical perspectives, yielded a low predictive model explaining only 12.8% of the total variance of goal attainment in this sample. As the knowledge base about predictors of goal attainment is scarce, an exploratory approach was warranted to generate new hypotheses for future work. This approach suggested that being female, having low levels of anxiety symptoms, experiencing good executive functioning as well as high rehabilitation expectations were related to positive goal attainment. This finding should be interpreted with caution as there is a risk of overestimating the association of single explanatory variables in univariate regression analyses, and future investigation is needed. Furthermore, it should be noted that although the exploratory model is significant, the explained variance is still modest (32.2%), which implies that there are factors associated with goal attainment that were not included in the current model.

The fact that both demographic factors, emotional symptoms, TBI-related deficits, and factors relating to the intervention itself may play a role in goal attainment is, however, not surprising but clinically very important. Rehabilitation is a complex, multifaceted process that involves many interacting factors, and the identification of active ingredients in rehabilitation interventions is notoriously difficult [76]. It is not surprising that individual factors may be associated with intervention outcomes. In our exploratory model, neither age, education level nor employment status predicted goal attainment. However, women displayed higher goal attainment. This finding needs replication. The literature on the influence of gender on outcome post-TBI is mixed [77]. Colantonio and colleagues [78] found that men reported larger difficulties than women in setting realistic goals, which might influence goal attainment. Other studies have suggested that women might have more intact executive functioning and better self-awareness post-TBI, but findings vary, and other authors have suggested that women show higher levels of self-awareness after

TBI [79]. Hence, we do not currently have any strong hypothesis regarding this result. The finding might even be spurious, in that gender is a proxy for a third and unknown variable. Interestingly, no injury-related factors were predictive of goal attainment. This could suggest that at the chronic stage of TBI, factors such as injury severity and time since injury do not play an important role in who benefits from every-day-oriented goal-based rehabilitation approaches. This supports the findings by Cicerone and colleagues that individuals with ongoing TBI-related difficulties should be offered support and may also benefit in the chronic stage, even years after the injury [25,26]. Additionally, self-reported executive dysfunction was shown to be detrimental to goal attainment, while performancebased cognitive impairments were not predictive of goal attainment. Thus, this only partly supports previous findings that cognitive impairment may hinder setting and achieving goals [42,43]. Despite previous findings that fatigue and emotional difficulties may be barriers to early goal-oriented rehabilitation in patients with stroke [80], only anxiety levels significantly predicted goal attainment in the current study. It may be that initial levels of fatigue and depression are a larger barrier to benefiting from rehabilitation during early recovery and are more addressable as the target of SMART goals later on. However, anxiety symptoms were shown to influence goal attainment. Anxiety levels are known to influence outcome post-TBI, although the directionality of this influence is disputed [81]. One study by Curran and colleagues [82] suggested that individuals with high levels of anxiety displayed more negative coping skills, such as worry, self-blame, and wishful thinking, and to some degree less positive coping skills such as problem solving. Whether anxiety symptoms in themselves are detrimental to goal attainment, or whether anxiety is a proxy for a variable such as coping skills is uncertain, and this finding also needs replication.

The finding that a positive expectation that the treatment could be beneficial during the third but not during the first session was predictive of goal attainment, was highly interesting. The finding may suggest that patient expectations are essential for goal attainment. However, as the wording of this question was the degree to which the participant expected that they would benefit from participating in the program, and that this belief was only predictive after participating in two or more sessions (and not at the very first session), it is likely that their response was influenced by their perceived level of therapeutic alliance. Although therapeutic alliance has received most attention in the field of psychotherapy, it has also been recognized as an important factor in brain injury rehabilitation (see [83] for a discussion). However, positive expectations might also be related to factors not measured in the current study. For example, the level of self-awareness may influence therapeutic alliance [44]. It may also be that expectations of change were influenced by the level of participant self-efficacy caused by the experienced improvement or lack thereof during the first three sessions. Self-efficacy, tenacity, and motivation have been previously shown to be predictive of goal attainment [34,41,44,45]. Future investigations should include measures of both therapeutic alliance, self-efficacy, and self-awareness in addition to change motivation to provide a clearer understanding of this interesting finding. The finding also indicated that treatment expectations should be discussed with patients early on in treatment, as this may play a role in treatment outcome. In summary, despite being exploratory, the current analyses provide hypotheses for further investigation of factors associated with goal attainment. Such investigations might be highly important to ensure a better understanding of what helps and what hinders goal attainment in rehabilitation, which again could help improve outcomes and ensure necessary tailoring of interventions.
