**1. Introduction**

Traumatic brain injury (TBI) is a costly condition with long-lasting impact for many individuals [1–3]. Persons who suffer a TBI might experience a variety of consequences, including difficulties with physical, cognitive, emotional, behavioral, vocational, and social functioning. Many experience persistently reduced quality of life and restrictions in community participation [4–9]. Families are also affected and may have to adapt to a new life with their injured family member being dependent on their assistance and support [10–14]. It has been increasingly recognized that TBI is a chronic condition with multiple and interacting effects on health and wellbeing [15–18], as a significant proportion of patients

**Citation:** Borgen, I.M.H.; Hauger, S.L.; Forslund, M.V.; Kleffelgård, I.; Brunborg, C.; Andelic, N.; Sveen, U.; Søberg, H.L.; Sigurdardottir, S.; Røe, C.; et al. Goal Attainment in an Individually Tailored and Home-Based Intervention in the Chronic Phase after Traumatic Brain Injury. *J. Clin. Med.* **2022**, *11*, 958. https://doi.org/10.3390/jcm11040958

Academic Editor: Kenji Dohi

Received: 22 November 2021 Accepted: 10 February 2022 Published: 12 February 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

continue to experience life-long difficulties and impaired functional status [8,19–22]. A challenge in rehabilitation after TBI is the heterogeneous nature of sequelae. Moreover, the patient's specific difficulties interact with contextual and psychosocial factors [23,24]. Hence, many individuals are in need of long-term support from health care services. Evidence suggests that rehabilitation can be effective in reducing symptom burden and in improving participation and quality of life, and also for those who experience persisting symptoms [25–28]. However, evidence suggests that one-third of patients with chronic TBI have unmet needs related to cognitive, emotional, and vocational functioning [29], and that certain symptoms, such as neuropsychiatric sequelae, might often be overlooked in rehabilitation [30].

Rehabilitation efforts have become increasingly focused on enhancing patient involvement [31], and person-centered rehabilitation has been shown to have positive effects on occupational performance and rehabilitation satisfaction [32]. Goal-oriented rehabilitation with patient involvement is considered a key approach to rehabilitation [33,34], and has been shown to increase patient satisfaction and adherence [35], as well as improve self-efficacy, health-related quality of life and emotional status. There is, however, a need for more methodologically rigorous studies involving the use of individualized and specific treatment goals [36]. Although some studies have demonstrated the utility of a goal-oriented approach in tailoring rehabilitation efforts to the heterogeneous functional difficulties due to persistent TBI symptoms [37,38], more high-quality studies are needed on the effect of such approaches in the chronic phase of TBI.

Although goal-oriented rehabilitation seems promising in chronic TBI, there might also be individual differences in the suitability of the approach. Many advocate that a high level of patient involvement is necessary in goal-oriented rehabilitation [34,39–41], and that patients with cognitive impairments are susceptible to being less involved in goal setting [42]. Cognitive impairment might, thus, lead to difficulties both with setting goals and with achieving them and should be explored when evaluating goal attainment [43]. Impaired self-awareness might be a particular challenge for patients with TBI, potentially influencing goal setting and engagement in rehabilitation [44]. Some studies have identified fatigue and emotional difficulties as potential barriers to early goal-oriented rehabilitation [45]. In addition, individual factors such as self-efficacy, tenacity, and motivation have further been identified as potential moderators of goal attainment [43,46,47]. To our knowledge, a systematic investigation of the degree to which cognitive impairment, emotional distress, demographic factors (i.e., age, gender, education), and/or injury-related variables predict goal attainment in the chronic phase of TBI has not yet been explored.

Despite the focus on goal-oriented rehabilitation over the past decades, conceptual terms vary, theoretical frameworks are often lacking [48,49], and there is a need to describe goal attainment [40,50], as goal attainment is rarely reported [51]. The SMART goal approach is frequently applied, i.e., setting goals that are Specific, Measurable, Achievable, Relevant, and Timed. Furthermore, the use of goal attainment scaling (GAS) [52] to measure goal attainment seems to be the best available alternative [53]. GAS is a systematic scoring of individualized goals in specific areas, which allows comparison of goal attainment across individualized goals and patients. GAS has been shown to be reliable, valid, and to have satisfactory responsiveness, as well as being sensitive to change [54]. Recently, Trevena-Peters, McKay [55] published results from a randomized controlled trial (RCT) supporting the effectiveness of an intervention to improve activities of daily living during post-traumatic amnesia, providing detailed results from GAS. A feasibility study of a project-based intervention for acquired brain injuries also detailed goal attainment results [56]. However, the studies neither provided information on the attainability of goals in distinct domains, nor did they investigate predictors of goal attainment.

The current study is modeled after a goal-oriented, home-based rehabilitation program shown to be effective in improving TBI-specific problem areas nominated by participants and which was shown to be highly acceptable for both patients and family members [57]. The current study represents an expansion and development of this approach in a different

cultural setting (i.e., Norway), in a civilian sample, and with more severe injuries. The design was expanded by including SMART goals and GAS scoring within a randomized controlled trial, resulting in the combination of an individually targeted and standardized intervention approach. In addition to reporting group-based outcomes on standardized measures in the RCT, the design allows for exploration of the functional domains where individuals with TBI report a need for rehabilitation efforts. It also allows description of the degree to which setting individualized goals within the individual problem areas results in positive goal attainment. The study thus addresses several of the weaknesses in the current literature that have been noted above.
