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Corresponding author Satoshi Tanaka, PhD, Laboratory of Psychology, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan.
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.
Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
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,
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
Rehabilitation professionals set rehabilitation goals, provide information regarding rehabilitation, and consider patient cultural norms to increase patient motivation.
However, although 15 motivational strategies, such as active listening and praise, were used by more than 75% of 362 professionals working in stroke rehabilitation,
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.
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.
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
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.
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,
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)
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
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
along with 6 strategies based on our clinical experience were selected. Stroke rehabilitation experts reviewed the items for clarity, relevance, and topic coverage.
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.
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.
Consequently, we prepared a list of 26 motivational strategies (table 1).
Table 1List of motivational strategies
Motivational Strategy
Definition
Active listening
Therapists listen to their patients carefully while showing interest and refraining from interrupting.
Allowing the patient to use a newly acquired skill
Therapists provide their patients opportunities to use newly acquired skills through rehabilitation practices.
Application of patient preferences to practice tasks
Therapists apply patient preferences, such as hobbies, to practice tasks.
Cognitive behavioral therapy
This 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 difficulty
Therapists gradually increase the difficulty of a task according to the ability of the patients.
Engaging in enjoyable conversation with the patient
Therapists engage in pleasant conversation with their patients to help them enjoy the rehabilitation process.
Engaging in practice alongside the patient
Therapists engage in practice alongside their patients.
Explaining the necessity of practice
Therapists explain the necessity of practice to their patients.
Goal-oriented practice
Therapists provide their patients practice tasks that are related to each patient’s rehabilitation goal.
Goal setting
Therapists set rehabilitation goals that are perceived by both the therapist and the patient as relevant and achievable.
Group rehabilitation
Therapists offer a group rehabilitation program.
Motivational interviewing
A collaborative conversation style that aims to strengthen an individual’s sense of motivation and commitment to change.
Practice with game-like properties
Therapists provide their patients with rehabilitation programs that have game-like properties such as virtual reality.
Practice related to the patient’s experience
Therapists provide practice tasks that patients can complete using their previous experience.
Praise
Therapists provide their patients with positive evaluations and encouragement.
Proposing conditions for exchange
Therapists 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 environment
Therapists provide a suitable rehabilitation environment so that patients can comfortably engage in practice.
Providing feedback regarding the results of the practice
Therapists provide verbal and/or visual feedback regarding the results of the practice to their patients.
Providing medical information
Therapists 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 treatments
Therapists allow their patients to consider how they could successfully perform the provided practice tasks.
Providing variations of the programs
Therapists provide variations of rehabilitation programs.
Recommending that family members are present during rehabilitation
Therapists recommend that the patient’s family members are present during rehabilitation.
Respect for self-determination
Therapists respect the patient’s self-determination.
Sharing the criteria for evaluation
Therapists share the criteria for evaluation with their patients.
Specifying the amount of practice required
Therapists 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.
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.
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.
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.
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 Strategy
Round 1 n=160
Round 2 n=123
Round 3 n=116
%
Control of task difficulty
5 (1)
5 (0)
5 (0)
87.1
Goal setting
5 (1)
5 (1)
5 (0)
81.0
Providing feedback regarding the results of the practice
5 (1)
5 (1)
5 (0)
78.4
Goal-oriented practice
4 (1)
5 (1)
5 (1)
73.3
Praise
4 (1)
5 (1)
5 (1)
69.8
Providing a suitable rehabilitation environment
4 (1)
5 (1)
5 (1)
66.4
Practice related to the patient’s experience
4 (1)
5 (1)
5 (1)
64.7
Allowing the patient to use a newly acquired skill
4 (0.75)
4 (1)
4 (1)
47.4
Sharing the criteria for evaluation
4 (1)
4 (1)
4 (1)
38.8
Application of patient preferences to practice tasks
4 (1)
4 (1)
4 (1)
35.3
Specifying the amount of practice required
4 (1)
4 (1)
4 (1)
34.5
Explaining the necessity of a practice
4 (1)
4 (1)
4 (1)
31.0
Respect for self-determination
4 (1)
4 (1)
4 (1)
31.0
Recommending that family members are present during rehabilitation
4 (1)
4 (1)
4 (1)
30.2
Active listening
NA
4 (1)
4 (1)
29.3
Providing variations of the programs
4 (1.75)
4 (1)
4 (1)
27.6
Having an enjoyable conversation with the patient
4 (0)
4 (1)
4 (1)
25.9
Engage in practice with the patient
4 (1.75)
4 (1)
4 (1)
25.9
Providing the patient opportunities to identify possible treatments
4 (1)
4 (0)
4 (0)
22.4
Motivational interviewing
4 (1)
4 (1)
4 (0)
20.7
Using progress-confirming tools
4 (1.75)
4 (0)
4 (0)
19.0
Providing medical information
4 (1)
4 (0)
4 (0)
19.0
Providing practice with game properties
4 (1)
4 (1)
4 (1)
10.3
Proposing conditions for exchange
3 (1)
3 (1)
3 (1)
6.9
Group rehabilitation
3 (1)
3 (1)
3 (1)
6.0
Cognitive behavioral therapy
3 (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 Information
Round 1 n=160
Round 2 n=123
Round 3 n=116
%
Cognitive function
5 (1)
5 (0)
5 (0)
85.3
Human environment
4 (1)
5 (1)
5 (1)
66.3
Personality
5 (1)
5 (1)
5 (1)
59.5
Patient’s reaction to a presented motivational strategy
4 (1)
5 (1)
5 (1)
56.9
Social environment
4 (1)
4 (1)
5 (1)
54.3
Severity of activity limitations
4 (1)
4 (1)
5 (1)
50.9
Physical function
4 (1)
4 (1)
4 (1)
44.0
Comorbidities
4 (1)
4 (1)
4 (1)
41.4
Diagnosis
4 (2)
4 (1)
4 (1)
35.3
Severity of participation restrictions
4 (1)
4 (1)
4 (1)
25.9
Demographic characteristics
4 (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.
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.
International consultation on urological diseases: evidence-based medicine overview of the main steps for developing and grading guideline recommendations.
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
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.
Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
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.
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.
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.
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.
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
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
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.
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
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
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.
References
Billinger S.A.
Arena R.
Bernhardt J.
et al.
Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
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.
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
Challenges faced with the implementation of web-based data query systems for population health: development of a questionnaire based on expert consensus.
International consultation on urological diseases: evidence-based medicine overview of the main steps for developing and grading guideline recommendations.
Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
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.
Supported by a JSPS KAKENHI grant to K.O. (grant no. 18K17730) and S.T. (grant nos. 16H03201 and 20H04050) and by an HUSM Grant-in-Aid to S.T. The funding source had no involvement in the study design, collection, analysis, and interpretation of data, writing of the report, or the decision to submit the article for publication.
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