*Aims*

The primary aim was to describe goal attainment in persons with persistent symptoms of TBI in the chronic phase. We hypothesized that participants would achieve goal attainment at expected levels. A second aim was to explore the functional domains of SMART goals established in the chronic phase and to determine whether goal attainment varied according to functional domains. We hypothesized that SMART goals would be related to physical/somatic, cognitive, emotional, and social problem areas typically seen in the chronic phase of TBI, and that goal attainment was achievable in all functional domains. Thirdly, we explored variables that might be associated with goal attainment, such as age, injury severity, and cognitive and emotional functioning. The existing literature does not give reason for a strong hypothesis regarding this aim; hence, this approach was considered exploratory in nature.

#### **2. Materials and Methods**

#### *2.1. Participants*

Participants were recruited from a two-group RCT conducted in Oslo, Norway. A detailed description of the study design is provided elsewhere [58]. Recruitment took place between June 2018 and December 2020. Between-group results of this trial will be published pending completion of 12 months follow-up assessments. Eligible participants were invited by letter, screened by phone, and, if eligible, invited to a baseline assessment at Oslo University Hospital (OUH). A family member was also invited if possible. Eligibility criteria were patients aged 18–72, with a TBI diagnosis with intracranial abnormalities verified by either computed tomography or magnetic resonance imaging. The participants had to be ≥16 years old at the time of injury, at least two years post-injury, and be living at home. Furthermore, they had to report ongoing TBI-related problems and/or reduced physical and mental health and/or difficulties with participation in their everyday life. Exclusion criteria were severe progressive neurologic or severe psychiatric disorders (including active substance abuse and violence), inability to provide informed consent, inability to participate in a goal-setting process, or insufficient fluency in Norwegian. After baseline assessment, participants were randomized 1:1 to either the control group or the intervention group by an independent researcher using a randomly generated number sequence. Participants in the control group received treatment as usual but no additional study-based treatment. Only patients randomized to the intervention group established SMART goals with subsequent GAS; hence, only results from the intervention group are reported in the current paper (*n* = 60).

#### *2.2. Intervention*

The intervention group received a home-based intervention consisting of eight contacts over a 4-month period. Initially, six home visits and two telephone calls were carried out. Due to the Covid-19 pandemic, some patients were followed up by phone only during the initial Norwegian lockdown in March–May 2020. A pragmatic solution was adapted to continue recruitment during the pandemic, and most participants included from May to December 2020 (*n* = 17) were offered one to two home visits (first, ±last), while six to seven meetings were conducted by videoconference or telephone. Figure 1 displays

an overview of the intervention sessions. Four therapists delivered the intervention: a medical doctor, a psychologist, a physiotherapist, and a neuropsychologist, all four with TBI rehabilitation expertise. Each participant was followed up by the same therapist throughout the intervention.

**Figure 1.** Overview of intervention sessions. \* Delivery format was adjusted due to the Covid-19 pandemic, i.e., videoconference (VC) and phone calls replaced some home visits to reduce risk of infection.

The intervention was manualized and based on the study by Winter et al. [57]. It contained three phases: (1) identification of target problem areas, (2) establishment of SMART goals and GAS for the selected target problems, and (3) development of an Action Plan consisting of strategies to achieve the goal. Figure 2 displays an example of an action plan. Goals were established through brainstorming between the patient, therapist, and family member, and included identification of needs for support, barriers to change, and current adaptive strategies to be built upon. There was no upper limit on the number of SMART goals for each patient, but new goals were not established after session 5. The process of establishing SMART goals, GAS, and Action plans was based on recommendations for collaborative goal setting from several authors [50,59,60]. Patients were presented with visual and verbal information about the SMART approach to goal setting, and the SMART approach was applied in a flexible manner to increase patient involvement. Specific and written strategies to be employed to reach the SMART goals were established, based on collaborative interactions between participants, family members, and therapists. Therapists suggested a range of therapeutic strategies based on the current evidence base for the specific target problem area, and a list of common strategies was built up throughout the study related to recurring functional areas of SMART goals. Therapists reviewed and updated

these strategies, and specific interventions were adopted to the individual needs of each patient. For details, see study protocol [58]. Team meetings were held on a regular basis, ensuring calibration of manual adherence across therapists. Ten percent of the sessions were observed by a senior professional with TBI expertise to evaluate treatment fidelity.

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**Figure 2.** Action plan example with SMART goal, strategies, and GAS. \* "As expected" here means the level you expect to accomplish before the program ends with a reasonable amount of effort.
