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Motivational Strategies for Stroke Rehabilitation: A Delphi Study

Open AccessPublished:August 01, 2020DOI:https://doi.org/10.1016/j.apmr.2020.06.007

      Abstract

      Objectives

      The primary objective was to provide a list of effective motivational strategies based on consensus among rehabilitation experts, generated using the Delphi technique. The secondary objective was to identify the types of information that are important when selecting motivational strategies.

      Design

      Delphi study.

      Setting

      On-site survey at academic conferences and web-based survey.

      Participants

      Rehabilitation experts (N=198) including physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least 5 years.

      Intervention

      Not applicable.

      Main Outcome Measures

      Panelists were asked to rate the effectiveness of motivational strategies and to rate the importance of different types of information using a 5-point Likert scale. Consensus was defined as having been reached for items with an interquartile range of 1 or less.

      Results

      A total of 116 experts (58.6%) completed the third round of the Delphi survey. Consensus was reached on all of the 26 presented strategies. Seven strategies, such as control of task difficulty and goal setting, were considered to be very effective in increasing patient motivation. In addition, all 11 of the presented types of information regarding patient health status, environmental factors, and personal factors were deemed very important or important in determining which motivational strategies to use.

      Conclusions

      We generated a list of effective motivational strategies for stroke rehabilitation based on expert consensus. Our results suggest that experts consider a comprehensive range of patient information when choosing motivational strategies. These findings represent a group of consensus-based recommendations for increasing patient adherence to stroke rehabilitation programs, which may be beneficial to many medical professionals working in stroke rehabilitation.

      Keywords

      List of abbreviations:

      IQR (interquartile range)
      Rehabilitation programs can improve functional capacity, ability related to daily activities, and quality of life.
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      • et al.
      Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
      High adherence to a prescribed rehabilitation program is regarded as indicative of motivation,
      • Maclean N.
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      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      and higher internal motivation at the beginning of a rehabilitation program appears to enhance outcomes in stroke patients.
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      Stroke patients motivation influence on the effectiveness of occupational therapy.
      Therefore, incorporating motivational strategies in rehabilitation programs may promote functional improvement after stroke.
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      • Stokes E.
      Addition of motivational interventions to exercise and traditional physiotherapy: a review and meta-analysis.
      Motivation is thought to critically influence motor and functional outcomes for individuals with a range of orthopedic and neurologic disorders. For example, virtual reality-based rehabilitation positively affects functional, psychological, and motivational factors in individuals with spinal cord injury,
      • de Araujo A.V.L.
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      Efficacy of virtual reality rehabilitation after spinal cord injury: a systematic review.
      and virtual reality can enhance motivation in interventions for children and adolescents with cerebral palsy.
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      Evidence for outcomes of motivational rehabilitation interventions for children and adolescents with cerebral palsy: an American Academy for Cerebral Palsy and Developmental Medicine systematic review.
      Psychological interventions including motivational interviewing and behavioral therapies such as goal setting therapy are widely used with individuals with acquired brain injury
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      Neurobehavioral initiation and motivation problems after acquired brain injury.
      and multiple sclerosis.
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      Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review.
      Furthermore, providing medical information and praise and encouragement helps patients with low back pain resume regular activities.
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      • Davidson M.
      • O'Halloran P.
      Motivational strategies for returning patients with low back pain to usual activities: a survey of physiotherapists working in Australia.
      Various strategies are used to motivate stroke patients in clinical practice with positive outcomes.
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      ,
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      • Dobkin B.H.
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      • Group S.
      International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes.
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      Motivational interviewing for improving recovery after stroke.
      • Forster A.
      • Brown L.
      • Smith J.
      • et al.
      Information provision for stroke patients and their caregivers.
      Rehabilitation professionals set rehabilitation goals, provide information regarding rehabilitation, and consider patient cultural norms to increase patient motivation.
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      However, although 15 motivational strategies, such as active listening and praise, were used by more than 75% of 362 professionals working in stroke rehabilitation,
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      consensus regarding the most effective strategies or the importance of specific types of information when selecting strategies has not been reached. Expert consensus regarding methods for selecting optimal strategies will help professionals increase patient adherence to stroke rehabilitation programs and improve patient outcome. The Delphi method is a well-known approach for developing expert consensus regarding topics where published evidence is scarce.
      • Hohmann E.
      • Brand J.C.
      • Rossi M.J.
      • Lubowitz J.H.
      Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
      This study aimed to use the Delphi method to generate a list of motivational strategies based on consensus among rehabilitation experts. We hypothesized that rehabilitation experts may use different motivational strategies according to the patient’s condition. Therefore, we also aimed to identify the types of information used when selecting motivational strategies.

      Methods

      Study design

      We conducted a Delphi study according to the guidance on conducting and reporting Delphi studies.
      • Junger S.
      • Payne S.A.
      • Brine J.
      • Radbruch L.
      • Brearley S.G.
      Guidance on conducting and reporting Delphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review.
      We used 3 Delphi rounds, as is typically thought to be sufficient to identify points of consensus.
      • Junger S.
      • Payne S.A.
      • Brine J.
      • Radbruch L.
      • Brearley S.G.
      Guidance on conducting and reporting Delphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review.
      • Diamond I.R.
      • Grant R.C.
      • Feldman B.M.
      • et al.
      Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies.
      • von der Gracht H.A.
      Consensus measurement in Delphi studies: review and implications for future quality assurance.

      Participants

      The Delphi method is an anonymous iterative survey of expert opinion.
      • Hasson F.
      • Keeney S.
      • McKenna H.
      Research guidelines for the Delphi survey technique.
      Here, we used a convenience sampling method to recruit experts in stroke rehabilitation at 2 rehabilitation conferences. Experts were defined as physicians, physical therapists, occupational therapists, and speech-language-hearing therapists who had worked in stroke rehabilitation for at least 5 years and were recruited with the cooperation of the 17th Annual Academic Conference of the Japanese Society of Neurological Physical Therapy and the 29th Annual Meeting of the Japan Society for Respiratory Care and Rehabilitation. We set up a booth inside the venue of each conference where participants could use provided laptops to voluntarily access a survey website containing a questionnaire.a To ensure privacy, the laptops were placed such that participants could not see each other’s responses. To publicize the study, we distributed leaflets to conference goers and placed posters at the front of the booth containing a brief study description and hyperlink to the survey. Participants could also access the survey website using their own electronic devices. In addition, we sent e-mail invitations to rehabilitation professionals who had participated in a preliminary survey study
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      and met the eligibility criteria for the present study. On the first page of the online survey, participants were asked to state their professional category, years of experience working in stroke rehabilitation, and the phase of stroke recovery with which they most frequently worked based on their practice setting. We defined acute, subacute, and chronic phases as less than 1 week, 1 week to 4 months, and more than 4 months after the onset of stroke, respectively.
      • Sullivan K.J.
      On “Modified constraint-induced therapy…” Page and Levine. Phys Ther. 2007;87:872-878.
      Those who met the eligibility criteria were invited to participate in the subsequent Delphi survey, while ineligible participants were thanked for their time and excluded from the study. The participants were asked to complete the questionnaire according to their experience with the type of patients with which they most frequency worked. We allowed the participants to contact us in the booth or by email if they encountered questions or difficulties completing the questionnaire. According to the Consensus-based Standards for the Selection of Health Measurement Instruments recommendations,
      • Terwee C.B.
      • Prisen C.
      • Chiarotto A.
      • et al.
      COSMIN methodology for assessing the content validity of PROMs—user manual version 1.0.
      we aimed to recruit at least 120 experts in the first round of the survey.

      Ethical considerations

      The study was approved by the appropriate ethics committees at the Hamamatsu University School of Medicine (approval no.: 19-048) and at the Shinshu University (approval no.: 4385). Informed consent was obtained from all participants.

      Developing the list of motivational strategies

      Here, motivation was defined as a function that orients and activates behavior according to content (ie, goal) and quantity (ie, goal value)
      • Pessiglione M.
      • Vinckier F.
      • Bouret S.
      • Daunizeau J.
      • Le Bouc R.
      Why not try harder? Computational approach to motivation deficits in neuro-psychiatric diseases.
      and motivational strategies as concrete tactics, techniques, or approaches to orient patients to rehabilitation.
      • Pessiglione M.
      • Vinckier F.
      • Bouret S.
      • Daunizeau J.
      • Le Bouc R.
      Why not try harder? Computational approach to motivation deficits in neuro-psychiatric diseases.
      ,
      • Guilloteaux M.J.
      • Dörnyei Z.
      Motivating language learners: a classroom-oriented investigation of the effects of motivational strategies on student motivation.
      We expected this definition to produce a large list of items used by rehabilitation professionals, with potential overlap among items. Rather than strictly define motivational strategies, we emphasized the applicability of the strategies in a clinical setting. Although some of the included motivational strategies were elements of good clinical practice (eg, active listening and praise), they were included because they are known to enhance patient participation in rehabilitation.
      A list of motivational strategies was initially developed based on data obtained from semistructured interviews,

      K.Oyake K. Kondo S. Tanaka Categorization of motivational strategies in rehabilitation based on ARCS model, In: Proceedings of the 34th Annual Conference of Japan Society for Educational Technology; 2018 Sept 28-30; Miyagi, Japan; 2018;667-668

      related literature,
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      ,
      • Dobkin B.H.
      • Plummer-D'Amato P.
      • Elashoff R.
      • Lee J.
      • Group S.
      International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes.
      ,
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      Qualitative analysis of stroke patients' motivation for rehabilitation.
      • Dobkin B.H.
      Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care.
      • Simpson L.A.
      • Eng J.J.
      • Tawashy A.E.
      Exercise perceptions among people with stroke: barriers and facilitators to participation.
      • Rimmer J.H.
      • Wang E.
      • Smith D.
      Barriers associated with exercise and community access for individuals with stroke.
      • Nicholson S.
      • Sniehotta F.F.
      • van Wijck F.
      • et al.
      A systematic review of perceived barriers and motivators to physical activity after stroke.
      • Nicholson S.L.
      • Greig C.A.
      • Sniehotta F.
      • et al.
      Quantitative data analysis of perceived barriers and motivators to physical activity in stroke survivors.
      • Damush T.M.
      • Plue L.
      • Bakas T.
      • Schmid A.
      • Williams L.S.
      Barriers and facilitators to exercise among stroke survivors.
      and the authors’ clinical experience. First, a list of 10 motivational strategies from semistructured interviews investigating how physical therapists with at least 5 years of stroke rehabilitation experience motivate stroke patients during rehabilitation was developed.

      K.Oyake K. Kondo S. Tanaka Categorization of motivational strategies in rehabilitation based on ARCS model, In: Proceedings of the 34th Annual Conference of Japan Society for Educational Technology; 2018 Sept 28-30; Miyagi, Japan; 2018;667-668

      Then, 6 strategies from previous studies
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      ,
      • Dobkin B.H.
      • Plummer-D'Amato P.
      • Elashoff R.
      • Lee J.
      • Group S.
      International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes.
      ,
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      Qualitative analysis of stroke patients' motivation for rehabilitation.
      • Dobkin B.H.
      Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care.
      • Simpson L.A.
      • Eng J.J.
      • Tawashy A.E.
      Exercise perceptions among people with stroke: barriers and facilitators to participation.
      • Rimmer J.H.
      • Wang E.
      • Smith D.
      Barriers associated with exercise and community access for individuals with stroke.
      • Nicholson S.
      • Sniehotta F.F.
      • van Wijck F.
      • et al.
      A systematic review of perceived barriers and motivators to physical activity after stroke.
      • Nicholson S.L.
      • Greig C.A.
      • Sniehotta F.
      • et al.
      Quantitative data analysis of perceived barriers and motivators to physical activity in stroke survivors.
      • Damush T.M.
      • Plue L.
      • Bakas T.
      • Schmid A.
      • Williams L.S.
      Barriers and facilitators to exercise among stroke survivors.
      along with 6 strategies based on our clinical experience were selected. Stroke rehabilitation experts reviewed the items for clarity, relevance, and topic coverage.
      • Artino Jr., A.R.
      • Durning S.J.
      • Sklar D.P.
      Guidelines for reporting survey-based research submitted to academic medicine.
      Following the expert review and a pilot study to test whether 4 rehabilitation professionals consistently understood the questions and instructions,
      • Kelley K.
      • Clark B.
      • Brown V.
      • Sitzia J.
      Good practice in the conduct and reporting of survey research.
      minor grammatical changes were made. The resulting list of 22 motivational strategies was then used in a cross-sectional survey study of more than 360 professionals to investigate the motivational strategies commonly used for stroke rehabilitation in clinical practice.
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      The survey included an open-ended question where respondents proposed additional strategies. As a result of the survey, 2 motivational strategies (“providing feedback regarding the results of the practice” and “engaging in practice alongside the patient”) were added to the list. Finally, motivational interviewing and cognitive behavioral therapy were added to the list because these strategies were regarded as motivational interventions in previous studies.
      • McGrane N.
      • Galvin R.
      • Cusack T.
      • Stokes E.
      Addition of motivational interventions to exercise and traditional physiotherapy: a review and meta-analysis.
      ,
      • Watkins C.L.
      • Auton M.F.
      • Deans C.F.
      • et al.
      Motivational interviewing early after acute stroke: a randomized, controlled trial.
      Consequently, we prepared a list of 26 motivational strategies (table 1).
      Table 1List of motivational strategies
      Motivational StrategyDefinition
      Active listeningTherapists listen to their patients carefully while showing interest and refraining from interrupting.
      Allowing the patient to use a newly acquired skillTherapists provide their patients opportunities to use newly acquired skills through rehabilitation practices.
      Application of patient preferences to practice tasksTherapists apply patient preferences, such as hobbies, to practice tasks.
      Cognitive behavioral therapyThis type of therapy helps patients regulate their emotions, achieve optimal levels of activity and function, and maintain realistic and optimistic thinking patterns.
      Control of task difficultyTherapists gradually increase the difficulty of a task according to the ability of the patients.
      Engaging in enjoyable conversation with the patientTherapists engage in pleasant conversation with their patients to help them enjoy the rehabilitation process.
      Engaging in practice alongside the patientTherapists engage in practice alongside their patients.
      Explaining the necessity of practiceTherapists explain the necessity of practice to their patients.
      Goal-oriented practiceTherapists provide their patients practice tasks that are related to each patient’s rehabilitation goal.
      Goal settingTherapists set rehabilitation goals that are perceived by both the therapist and the patient as relevant and achievable.
      Group rehabilitationTherapists offer a group rehabilitation program.
      Motivational interviewingA collaborative conversation style that aims to strengthen an individual’s sense of motivation and commitment to change.
      Practice with game-like propertiesTherapists provide their patients with rehabilitation programs that have game-like properties such as virtual reality.
      Practice related to the patient’s experienceTherapists provide practice tasks that patients can complete using their previous experience.
      PraiseTherapists provide their patients with positive evaluations and encouragement.
      Proposing conditions for exchangeTherapists propose conditions for exchange to their patients. For example, therapists promise that patients can do their favorite practice task after completing their least favorite practice task.
      Providing a suitable rehabilitation environmentTherapists provide a suitable rehabilitation environment so that patients can comfortably engage in practice.
      Providing feedback regarding the results of the practiceTherapists provide verbal and/or visual feedback regarding the results of the practice to their patients.
      Providing medical informationTherapists provide their patients with information such as the nature of recovery and how patients could expect to live at home.
      Providing the patient opportunities to identify possible treatmentsTherapists allow their patients to consider how they could successfully perform the provided practice tasks.
      Providing variations of the programsTherapists provide variations of rehabilitation programs.
      Recommending that family members are present during rehabilitationTherapists recommend that the patient’s family members are present during rehabilitation.
      Respect for self-determinationTherapists respect the patient’s self-determination.
      Sharing the criteria for evaluationTherapists share the criteria for evaluation with their patients.
      Specifying the amount of practice requiredTherapists clearly explain the amount of practice that will be required to their patients.
      Using progress-confirming tools (eg, diary, graphs)Therapists recommend that their patients use tools such as a diary or graphs that enable the patients to track their progress.
      NOTE. Motivational strategies are arranged in alphabetical order.
      In addition, we prepared a list of 11 types of information regarding patient health status, environmental factors, and personal factors (box 1). We used this list to identify which types of information are considered important when selecting motivational strategies.
      Types of information considered by rehabilitation professionals when choosing motivational strategies
      Tabled 1
      Type of Information
      Cognitive function (eg, cognitive deficits, dementia)
      Comorbidities (eg, psychological disorders, diabetes mellitus, infection)
      Demographic characteristics (eg, age, sex)
      Diagnosis (eg, ischemic or hemorrhagic, lesion site, recurrence)
      Human environment (eg, key person, family)
      Patient’s reaction to a presented motivational strategy
      Personality
      Physical function (eg, muscle weakness, limited range of motion)
      Severity of activity limitations
      Severity of participation restrictions
      Social environment (eg, economic condition, employment status)
      NOTE. Information types are arranged in alphabetical order.

      Delphi method

      The Delphi survey was conducted between September and December 2019. To maximize response rates, reminder e-mails were sent 1 and 2 weeks after each questionnaire. Panelists who completed the third round questionnaire received 1000 yen (approximately U.S. $9.00).
      In the first survey round, panelists were shown 25 of the motivational strategies and 11 types of patient information. “Active listening” was not included in the list of motivational strategies in the first round owing to a technical error but was added in the second and third rounds. Panelists were asked to rate the effectiveness of each motivational strategy and the importance of each type of information using a 5-point Likert scale (1=very ineffective/not at all important, 2=ineffective/unimportant, 3=uncertain, 4=effective/important, and 5=very effective/very important).
      The second and third round questionnaires were sent to panelists who completed the questionnaire from the previous round. In these rounds, the lists of 26 motivational strategies (including “active listening”) and 11 types of information were once again presented to the panelists. The response data for each strategy and type of information from the previous round were added as a reference, including a pie chart showing the distribution of responses and the mean rating score. After reviewing the results of the previous round, all panelists were asked to reconsider their previous ratings and to rate each item again to establish consensus with the other participants.
      • Junger S.
      • Payne S.A.
      • Brine J.
      • Radbruch L.
      • Brearley S.G.
      Guidance on conducting and reporting Delphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review.

      Data analysis

      To examine the effectiveness of each motivational strategy and the importance of each type of information, we calculated the median and interquartile range (IQR) on a 5-point Likert scale for each item.
      • De Vet E.
      • Brug J.
      • De Nooijer J.
      • Dijkstra A.
      • De Vries N.K.
      Determinants of forward stage transitions: a Delphi study.
      Items with an IQR of 1 or less are considered to demonstrate good consensus on a 5-point Likert scale.
      • von der Gracht H.A.
      Consensus measurement in Delphi studies: review and implications for future quality assurance.
      ,
      • Ahuja M.
      • Aseltine R.
      • Warren N.
      • Reisine S.
      • Williams P.H.
      • Cislo A.
      Challenges faced with the implementation of web-based data query systems for population health: development of a questionnaire based on expert consensus.
      Therefore, consensus was defined as an IQR of 1 or less. Subgroup analyses were performed for strategies for which consensus was reached and strategy ratings of effectiveness according to the (1) phase of stroke recovery of the patients with which the panelists most frequently worked, (2) panelist sex, (3) years of experience in stroke rehabilitation, and (4) professional category.

      Results

      Participants

      Of the 198 rehabilitation experts who accessed the survey website, 160 experts (80.8%) completed the first survey round. The panelist characteristics are shown in table 2. The majority of participants were physical therapists (76.9%). Responses were obtained from 123 panelists (62.1%) and 116 panelists (58.6%) in the second and third rounds, respectively. The flow of participants during the 3 rounds of the Delphi survey is shown in fig 1.
      Table 2Panelist characteristics (n=160)
      VariablesValue, n (%)
      Professional category
       Physical therapist123 (76.9)
       Occupational therapist29 (18.1)
       Physician5 (3.1)
       Speech-language-hearing therapist3 (1.9)
      Years of experience in stroke rehabilitation
       5-9 y98 (61.2)
       10-14 y38 (23.8)
       15 y or more24 (15.0)
      Sex
       Male128 (80)
       Female32 (20)
      Primary affiliation
       Hospital130 (81.3)
       Others30 (18.7)
      Phase of stroke recovery of the patients
       Subacute72 (45.0)
       Acute54 (33.8)
       Chronic34 (21.1)
      Figure thumbnail gr1
      Fig 1Flow diagram of the panelist response rates and withdrawals by round.

      Which motivational strategies did experts deem effective for stroke rehabilitation?

      The results of the Delphi survey on the effectiveness of each motivational strategy for stroke rehabilitation are shown in table 3. In the first round, consensus was achieved regarding 22 of the strategies. “Control of task difficulty,” “goal setting,” and “providing feedback regarding the results of the practice” were deemed very effective. Nineteen strategies, including “goal-oriented practice” and “praise,” were considered effective in motivating patients with stroke to engage in rehabilitation practices.
      Table 3Effectiveness of each motivational strategy for stroke rehabilitation
      Motivational StrategyRound 1 n=160Round 2 n=123Round 3 n=116%
      Control of task difficulty5 (1)5 (0)5 (0)87.1
      Goal setting5 (1)5 (1)5 (0)81.0
      Providing feedback regarding the results of the practice5 (1)5 (1)5 (0)78.4
      Goal-oriented practice4 (1)5 (1)5 (1)73.3
      Praise4 (1)5 (1)5 (1)69.8
      Providing a suitable rehabilitation environment4 (1)5 (1)5 (1)66.4
      Practice related to the patient’s experience4 (1)5 (1)5 (1)64.7
      Allowing the patient to use a newly acquired skill4 (0.75)4 (1)4 (1)47.4
      Sharing the criteria for evaluation4 (1)4 (1)4 (1)38.8
      Application of patient preferences to practice tasks4 (1)4 (1)4 (1)35.3
      Specifying the amount of practice required4 (1)4 (1)4 (1)34.5
      Explaining the necessity of a practice4 (1)4 (1)4 (1)31.0
      Respect for self-determination4 (1)4 (1)4 (1)31.0
      Recommending that family members are present during rehabilitation4 (1)4 (1)4 (1)30.2
      Active listeningNA4 (1)4 (1)29.3
      Providing variations of the programs4 (1.75)4 (1)4 (1)27.6
      Having an enjoyable conversation with the patient4 (0)4 (1)4 (1)25.9
      Engage in practice with the patient4 (1.75)4 (1)4 (1)25.9
      Providing the patient opportunities to identify possible treatments4 (1)4 (0)4 (0)22.4
      Motivational interviewing4 (1)4 (1)4 (0)20.7
      Using progress-confirming tools4 (1.75)4 (0)4 (0)19.0
      Providing medical information4 (1)4 (0)4 (0)19.0
      Providing practice with game properties4 (1)4 (1)4 (1)10.3
      Proposing conditions for exchange3 (1)3 (1)3 (1)6.9
      Group rehabilitation3 (1)3 (1)3 (1)6.0
      Cognitive behavioral therapy3 (1)3 (1)3 (1)5.2
      NOTE. Values are presented as the group median (IQR) on the 5-point Likert scale. The 5-point Likert scale ranges from 1-5, from very ineffective to very effective, respectively. The percent column denotes the percentage of panelists who selected 5 (very effective) in round 3. Motivational strategies are arranged in descending order with respect to the value shown in the percent column.
      Abbreviation: NA, not available owing to a technical error.
      In the second round, consensus was reached for all of the 26 presented strategies. In addition to the 3 strategies considered very effective in the first round, “goal-oriented practice,” “praise,” “providing a suitable rehabilitation environment,” and “practice related to the patient’s experience” were also regarded as very effective strategies. Sixteen strategies were considered effective strategies. The results of the third round were similar to those obtained in the second round. “Proposing conditions for exchange,” “group rehabilitation,” and “cognitive behavioral therapy” were rated as uncertain during the 3 rounds.
      In subgroup analyses, the ratings of effectiveness for each motivational strategy were similar regardless of the phases of stroke recovery of the patients for whom panelists were responsible. However, we found the difference in the number of strategies where consensus was reached. Panelists working in subacute rehabilitation and those who working in chronic rehabilitation reached consensus on all of the 26 strategies, while those who worked in acute stroke rehabilitation reached consensus on all strategies except for “motivational interviewing” (IQR, 1.25). Regardless of panelist sex, years of experience in stroke rehabilitation, and whether the panelists were physical therapists, consensus was reached for all 26 strategies. There were no differences in the ratings of effectiveness for each motivational strategy according to these factors.

      Which types of information do experts consider important when choosing motivational strategies?

      The results of the Delphi survey on the importance of different types of information when selecting motivational strategies are shown in table 4. In the first round, consensus was reached for 9 of the presented 11 items. “Cognitive function” and “personality” were considered to be very important types of information. Seven types of information were deemed important.
      Table 4Importance of each type of information when selecting motivational strategies
      Type of InformationRound 1 n=160Round 2 n=123Round 3 n=116%
      Cognitive function5 (1)5 (0)5 (0)85.3
      Human environment4 (1)5 (1)5 (1)66.3
      Personality5 (1)5 (1)5 (1)59.5
      Patient’s reaction to a presented motivational strategy4 (1)5 (1)5 (1)56.9
      Social environment4 (1)4 (1)5 (1)54.3
      Severity of activity limitations4 (1)4 (1)5 (1)50.9
      Physical function4 (1)4 (1)4 (1)44.0
      Comorbidities4 (1)4 (1)4 (1)41.4
      Diagnosis4 (2)4 (1)4 (1)35.3
      Severity of participation restrictions4 (1)4 (1)4 (1)25.9
      Demographic characteristics4 (2)4 (1)4 (0)21.6
      NOTE. Values are presented as the group median (IQR) on the 5-point Likert scale. The 5-point Likert scale ranges from 1-5, from not at all important to very important, respectively. The percent column denotes the percentage of panelists who selected 5 (very important) in round 3. Types of information are arranged in descending order with respect to the value shown in the percent column.
      In the second round, consensus was achieved for all 11 types of information. “Human environment,” “patient’s reaction to a presented motivational strategy,” “cognitive function,” and “personality” were considered very important. The other 7 types of information were regarded as important.
      After the third round, “social environment” and “severity of activity limitations” were also deemed very important, while 5 other types of information were considered important.

      Discussion

      We generated a list of motivational strategies for stroke rehabilitation based on expert consensus. Twenty-three strategies were deemed very effective or effective in motivating patients with stroke to engage in rehabilitation practices. Our results show that rehabilitation experts consider a comprehensive range of patient information when choosing motivational strategies. These findings can be used to generate consensus-based recommendations regarding motivational strategies for stroke rehabilitation.
      To our knowledge, this study is the first to establish consensus among experts regarding motivational strategies for stroke rehabilitation using the Delphi method. Expert opinion is regarded as the lowest grade of evidence.
      • Atkins D.
      • Best D.
      • Briss P.A.
      • et al.
      Grading quality of evidence and strength of recommendations.
      However, the Delphi technique is characterized by following 4 methodological features: (1) a group of experts is questioned about the issue of interest; (2) the process is anonymous to avoid social pressure and conformity to a dominant view; (3) the procedure is iterative in nature, comprising several rounds of enquiry; and (4) the design of subsequent rounds is informed by a summary of the group response of the previous round.
      • Junger S.
      • Payne S.A.
      • Brine J.
      • Radbruch L.
      • Brearley S.G.
      Guidance on conducting and reporting Delphi studies (CREDES) in palliative care: recommendations based on a methodological systematic review.
      Therefore, the Delphi process can enhance the authority of expert opinion
      • Abrams P.
      • Khoury S.
      International consultation on urological diseases: evidence-based medicine overview of the main steps for developing and grading guideline recommendations.
      in addition to generating an evidence base in situations where evidence is insufficient.
      • Hohmann E.
      • Brand J.C.
      • Rossi M.J.
      • Lubowitz J.H.
      Expert opinion is necessary: Delphi panel methodology facilitates a scientific approach to consensus.
      Because evidence-based motivational strategies have not yet been established for stroke rehabilitation, a consensus of expert opinion generated using the Delphi method may be beneficial in helping rehabilitation professionals enhance patient motivation. Our sample size was determined according to the Consensus-based Standards for the Selection of Health Measurement Instruments recommendations
      • Terwee C.B.
      • Prisen C.
      • Chiarotto A.
      • et al.
      COSMIN methodology for assessing the content validity of PROMs—user manual version 1.0.
      and was large (116 participants) compared with previous Delphi studies,
      • Diamond I.R.
      • Grant R.C.
      • Feldman B.M.
      • et al.
      Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies.
      which is an important strength of the present study.

      Which motivational strategies did experts deem effective for stroke rehabilitation?

      We observed changes in the median scores over the 3 rounds, which were influenced by feedback from the previous round. Consequently, we found 7 very effective strategies for motivating patients with stroke to engage in rehabilitation practices. Of these, all except for “providing feedback regarding the results of the practice” were used by more than 75% of the rehabilitation professionals in a previous study.
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      Gradual increases in task difficulty and goal-oriented practice have been recommended to promote functional recovery during stroke rehabilitation.
      • Winstein C.J.
      • Stein J.
      • Arena R.
      • et al.
      Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
      Because inappropriate levels of task difficulty can bore or frustrate the patient,
      • Pan L.
      • Song A.
      • Wang S.
      • Duan S.
      Experimental study on upper-limb rehabilitation training of stroke patients based on adaptive task level: a preliminary study.
      gradually increasing task difficulty according to the ability of the patient may help enhance patient adherence to a rehabilitation program. Setting rehabilitation goals can also have a positive effect on stroke recovery during rehabilitation.
      • Sugavanam T.
      • Mead G.
      • Bulley C.
      • Donaghy M.
      • van Wijck F.
      The effects and experiences of goal setting in stroke rehabilitation - a systematic review.
      Therefore, these strategies appear to be very effective for motivating patients with stroke during rehabilitation.
      Sixteen strategies, such as “respect for self-determination” and “active listening,” were deemed effective in increasing patient motivation. Self-determination facilitates and maintains intrinsic motivation.
      • Ryan R.M.
      • Deci E.L.
      Intrinsic and extrinsic motivations: classic definitions and new directions.
      Active listening is a core communication skill involved in motivational interviewing,
      • Cheng D.
      • Qu Z.
      • Huang J.
      • Xiao Y.
      • Luo H.
      • Wang J.
      Motivational interviewing for improving recovery after stroke.
      ,
      • Watkins C.L.
      • Auton M.F.
      • Deans C.F.
      • et al.
      Motivational interviewing early after acute stroke: a randomized, controlled trial.
      and undergoing motivational interviewing has been associated with normal mood.
      • Cheng D.
      • Qu Z.
      • Huang J.
      • Xiao Y.
      • Luo H.
      • Wang J.
      Motivational interviewing for improving recovery after stroke.
      Thus, the value of some strategies considered effective in this study is supported by positive effects on recovery after stroke.
      Our results are consistent with those of previous studies regarding motivation strategies for rehabilitation in individuals with other conditions, such as spinal cord injury, cerebral palsy, and low back pain.
      • de Araujo A.V.L.
      • Neiva J.F.O.
      • Monteiro C.B.M.
      • Magalhaes F.H.
      Efficacy of virtual reality rehabilitation after spinal cord injury: a systematic review.
      • Tatla S.K.
      • Sauve K.
      • Virji-Babul N.
      • Holsti L.
      • Butler C.
      • Van Der Loos H.F.
      Evidence for outcomes of motivational rehabilitation interventions for children and adolescents with cerebral palsy: an American Academy for Cerebral Palsy and Developmental Medicine systematic review.
      • Palmisano S.
      • Fasotti L.
      • Bertens D.
      Neurobehavioral initiation and motivation problems after acquired brain injury.
      • Dorstyn D.S.
      • Mathias J.L.
      • Bombardier C.H.
      • Osborn A.J.
      Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review.
      • Holden J.
      • Davidson M.
      • O'Halloran P.
      Motivational strategies for returning patients with low back pain to usual activities: a survey of physiotherapists working in Australia.
      Therefore, effective motivational strategies observed in this study, such as control of task difficulty and goal setting, may be incorporated into rehabilitation programs for these individuals.

      Which types of information do experts consider important when choosing the motivational strategies?

      Our data support previous findings regarding factors related to motivation in stroke patients
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      ,
      • Rimmer J.H.
      • Wang E.
      • Smith D.
      Barriers associated with exercise and community access for individuals with stroke.
      ,
      • Nicholson S.
      • Sniehotta F.F.
      • van Wijck F.
      • et al.
      A systematic review of perceived barriers and motivators to physical activity after stroke.
      ,
      • Damush T.M.
      • Plue L.
      • Bakas T.
      • Schmid A.
      • Williams L.S.
      Barriers and facilitators to exercise among stroke survivors.
      ,
      • Morris J.
      • Oliver T.
      • Kroll T.
      • Macgillivray S.
      The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature.
      and suggest that the following are regarded as particularly essential when choosing motivational strategies: the severity of cognitive impairments and activity limitations, human and social environments, patient personality type, and patient responses to motivational strategies. Furthermore, our results suggest that experts adjust their motivational strategies according to patient preferences and reactions. Further studies are needed to evaluate the motivational strategies that rehabilitation experts use according to patient condition.

      Study limitations

      There exist several limitations to the present study. First, all of the panelists were recruited in Japan, which may limit the international generalizability of our findings. Although the motivational strategies were defined in the questionnaire and panelists could ask for clarification regarding the survey items, our supplemental survey showed that less than 50% of the panelists (45.6%) were familiar with cognitive behavioral therapy. Thus, the low ratings of effectiveness for cognitive behavioral therapy were likely because of a low degree of recognition among rehabilitation experts in Japan. With the exception of our data for cognitive behavioral therapy, our results are consistent with those of some previous qualitative
      • Maclean N.
      • Pound P.
      • Wolfe C.
      • Rudd A.
      The concept of patient motivation: a qualitative analysis of stroke professionals' attitudes.
      ,
      • Rimmer J.H.
      • Wang E.
      • Smith D.
      Barriers associated with exercise and community access for individuals with stroke.
      ,
      • Nicholson S.
      • Sniehotta F.F.
      • van Wijck F.
      • et al.
      A systematic review of perceived barriers and motivators to physical activity after stroke.
      ,
      • Damush T.M.
      • Plue L.
      • Bakas T.
      • Schmid A.
      • Williams L.S.
      Barriers and facilitators to exercise among stroke survivors.
      ,
      • Morris J.
      • Oliver T.
      • Kroll T.
      • Macgillivray S.
      The importance of psychological and social factors in influencing the uptake and maintenance of physical activity after stroke: a structured review of the empirical literature.
      and experimental
      • Dobkin B.H.
      • Plummer-D'Amato P.
      • Elashoff R.
      • Lee J.
      • Group S.
      International randomized clinical trial, stroke inpatient rehabilitation with reinforcement of walking speed (SIRROWS), improves outcomes.
      • Cheng D.
      • Qu Z.
      • Huang J.
      • Xiao Y.
      • Luo H.
      • Wang J.
      Motivational interviewing for improving recovery after stroke.
      • Forster A.
      • Brown L.
      • Smith J.
      • et al.
      Information provision for stroke patients and their caregivers.
      ,
      • Sugavanam T.
      • Mead G.
      • Bulley C.
      • Donaghy M.
      • van Wijck F.
      The effects and experiences of goal setting in stroke rehabilitation - a systematic review.
      ,
      • Prakash V.
      • Shah M.A.
      • Hariohm K.
      Family's presence associated with increased physical activity in patients with acute stroke: an observational study.
      • Sonoda S.
      • Saitoh E.
      • Nagai S.
      • Kawakita M.
      • Kanada Y.
      Full-time integrated treatment program, a new system for stroke rehabilitation in Japan: comparison with conventional rehabilitation.
      • Michimata A.
      • Suzukamo Y.
      • Izumi S.-I.
      Development of clinicians’ communication skills influences the satisfaction, motivation, and quality of life of patients with stroke.
      • Laver K.E.
      • Lange B.
      • George S.
      • Deutsch J.E.
      • Saposnik G.
      • Crotty M.
      Virtual reality for stroke rehabilitation.
      • Popović M.D.
      • Kostić M.D.
      • Rodić S.Z.
      • Konstantinović L.M.
      Feedback-mediated upper extremities exercise: increasing patient motivation in poststroke rehabilitation.
      studies from Western countries. An international Delphi survey would improve the external validity of our findings.
      Second, we used convenience sampling to recruit participants, and so they may have been more interested in motivational strategies compared with nonparticipants. Therefore, the effectiveness of each motivational strategy may be overestimated. Third, because the majority of the participants were physical therapists, their opinions might be overstated in the data. However, the present data suggest that whether the participants were physical therapists did not appear to modulate the perception of effectiveness for each motivational strategy. There are approximately 172,000 licensed physical therapists in Japan
      Japanese Physical Therapy Association.
      and approximately 80,000 occupational therapists,
      Japanese Association of Occupational Therapists.
      30,000 speech-language-hearing therapists,
      Japanese Association of Speech-Language Therapists.
      and 2500 board-certified physiatrists.
      Japanese Association of Rehabilitation Medicine.
      Thus, the ratio of physical therapists in our sample appears to be consistent with the actual situation in Japan. Nonetheless, a random sampling method might minimize this sampling bias. Fourth, including some participants from the preliminary study
      • Oyake K.
      • Suzuki M.
      • Otaka Y.
      • Tanaka S.
      Motivational strategies for stroke rehabilitation: a descriptive cross-sectional study.
      may bias the results of the present study, although our supplemental analysis showed that the perception of effectiveness for each motivational strategy was similar regardless of whether the panelists had participated in the preliminary study. Finally, we did not examine how patients or caregivers perceived the effectiveness of each motivational strategy. Thus, future studies are needed to investigate this point.

      Conclusions

      To our knowledge, this study is the first to generate a list of motivational strategies for stroke rehabilitation based on expert consensus. Seven motivational strategies, including controlling task difficulty and setting rehabilitation goals, were deemed very effective. In addition, 16 strategies were considered effective in increasing patient motivation. These findings may be useful for developing consensus-based recommendations regarding motivational strategies for use in stroke rehabilitation.

      Supplier

      • a.
        Google Forms tool; Google.
      NOTE. Values are presented as the group median (IQR) on the 5-point Likert scale. The 5-point Likert scale ranges from 1-5, from very ineffective to very effective, respectively. The percent column denotes the percentage of panelists who selected 5 (very effective) in round 3. Motivational strategies are arranged in descending order with respect to the value shown in the percent column.
      Abbreviation: NA, not available owing to a technical error.

      Acknowledgment

      We thank Sydney Koke, MFA, from Edanz Group (www.edanzediting.com/ac) for editing a draft of this manuscript.

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