Further validation of the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire (MOT-Q) in patients with acquired brain injury

The relationship between rehabilitation motivation and upper limb motor function in stroke patients

Objective

Insufficient motivation among post-stroke survivors may be an important factor affecting their motor function recovery. This study seeks to investigate the relationship between motivation and functional recovery in stroke patients undergoing rehabilitation training.

Materials and methods

103 stroke patients with upper limb impairments were studied during their hospital stays. Assessments were done before and after rehabilitation training to measure motivation, emotional state, motor function, and independence in daily activities. Data analysis was conducted to examine the distribution of these factors among the participants. Pearson and Spearman correlation analyses were used to study the relationships between motivation, emotional state, and motor function. Patients were divided into high and low motivation groups based on the Rehabilitation Motivation Scale (RMS), and chi-square and rank-sum tests were used to compare functional differences before and after treatment among patients with varying levels of motivation.

Results

66 participants were found to have low motivation in the initial assessment of the RMS (64.08%). Consistency in motivation levels was observed among patients with high motivation (r = 0.648, P<0.001). Apathy was identified as the main factor affecting motivation in patients with low motivation (p = 0.027), while depression and anxiety were not significantly correlated. Motivation was strongly linked to improvements in upper limb motor function, daily living activities, and self-exercise duration (p < 0.001) for stroke patients undergoing rehabilitation. Post-training, there was a notable increase in motivation, motor function, and independence in daily activities (p < 0.001). Increased rehabilitation motivation was linked to better upper limb motor function and daily independence in patients, particularly those with low motivation. This correlation was significant for both the FMA-UE and FIM scores.

Discussion

Old patients with poor upper limb motor function often have low motivation, which hinders their recovery. Using strategies to boost motivation in stroke patients with impaired upper limb function could greatly improve their rehabilitation and motor skills. It is crucial to prioritize these intervention strategies.

Conclusion

Enhancing rehabilitation motivation in stroke patients with low motivation and upper limb motor impairments can foster the restoration of their functional capabilities.

Socratic guided feedback therapy after acquired brain injury: A multicenter randomized controlled trial to evaluate effects on self-awareness

Impaired self-awareness after acquired brain injury (ABI) challenges neuropsychological rehabilitation. The current study aimed to compare the effects of Socratic Guided Feedback therapy to usual care in a multicenter randomized controlled trial with 64 participants with reduced self-awareness after ABI. The objectives were to study the effects on (1) self-awareness and (2) motivation for and participation in therapy, mood, quality of life, and social participation. Patients were recruited from rehabilitation centres in The Netherlands and Belgium. They were 50.8 (±16) years old and 2.7 months (±1.8) post-injury at baseline. Session duration ranged from 20-60 minutes and the number of sessions ranged from 1 to 162 sessions. Self-awareness increased over time in both groups. Between 9 and 12 months after baseline measurement, self-awareness (Patient Competency Rating Scale discrepancy score between patient and significant other) improved in the experimental group and deteriorated in care as usual. No significant differences were found on secondary outcome measures. In conclusion, Socratic Guided Feedback therapy is as effective as care as usual but provides a structure for therapists. We recommend further investigation of the added value of Socratic Guided Feedback therapy in later follow-up measurements, group therapy settings, and on other outcome domains such as caregiver burden.

Mixed methods, single case design, feasibility trial of a motivational conversational agent for rehabilitation for adults with traumatic brain injury

OBJECTIVE

Rehabilitation for adults with traumatic brain injury (TBI) incorporates client-centred goal-setting and motivational support to achieve goals. However, face-to-face rehabilitation is time-limited. New therapy approaches which leverage care are warranted. Conversational agents (CAs) offer a human-computer interface with which a person can converse. This study tested the feasibility, usability and acceptability of using a novel CA - RehabChat - alongside brain injury rehabilitation.

DESIGN

Mixed methods, single case design, feasibility pilot trial.

SETTING

Ambulatory and community brain injury rehabilitation.

PARTICIPANTS

Adults with TBI receiving brain injury rehabilitation and clinicians providing this care.

INTERVENTION

Following 1:1 training, client-clinician dyads used RehabChat for two weeks alongside usual care.

MAIN MEASURES

Pre-post clinical measures (Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, Rehabilitation Therapy Engagement Scale, Brain Injury Rehabilitation Trust Motivation Questionnaire-Relative, Brain Injury Rehabilitation Trust Motivation Questionnaire-Self) repeated measures (Hospital Anxiety and Depression Scale, researcher-developed wellbeing screening questions); and post-intervention (System Usability Scale (SUS), semi-structured 1:1 interview).

RESULTS

Six participants (two clients and four clinicians) completed training. Two client-clinician dyads completed the intervention. Two other clinicians used RehabChat in a mock client-clinician session. SUS scores indicated good usability. Client well-being did not deteriorate. No adverse events were experienced. Interviews indicated RehabChat was feasible, acceptable and easy to use; and supported motivation, goal-setting and completing practice activities.

CONCLUSIONS

RehabChat was feasible and acceptable to use alongside usual ambulatory and community brain injury rehabilitation, had good usability and supported client needs. Further testing of RehabChat with a larger cohort for longer duration is warranted.

Game-supported cognitive strategy training for slowed information processing speed after acquired brain injury: study protocol for a randomised controlled trial

INTRODUCTION

Many individuals with acquired brain injury tend to experience problems with slowed information processing speed (IPS). A potentially beneficial and cost-effective supplement for cognitive rehabilitation of impaired IPS may be the implementation of serious gaming that focuses on compensatory learning as part of cognitive training. However, most digital platforms used during cognitive rehabilitation focus on restoring cognitive function and evidence for skill transfer from digital practice to everyday life is lacking. This study aims to investigate the efficacy of a game-supported cognitive strategy training. The training combines a well-validated time pressure management cognitive strategy training, targeting slowed IPS, with a novel game and a mobile application. The game-supported training focuses on the generalisation of strategy-use to untrained tasks in everyday life.

METHODS AND ANALYSIS

The study is designed as a randomised controlled trial in which the experimental group (Karman Line - Tempo module: an 8-week game-supported cognitive strategy training) will be compared with an active control group (CogniPlus training: an 8-week computerised cognitive function training). Data from 60 individuals with acquired brain injury (30 per group, ages between 16 and 75) will be collected at baseline (T0), post-treatment (T1) and at 3-month follow-up (T2). The primary outcome measure is an objective assessment of compensatory strategy use in an untrained experimental task. The secondary outcome is the attainment of trained and untrained treatment goals assessed by goal attainment scaling. Pre-training and post-training data will be analysed using a 2×2 repeated measure analysis of variance.

ETHICS AND DISSEMINATION

This study has been approved by the medical review ethics committee CMO Region Arnhem and Nijmegen (NL74818.091.20) and is registered in the Netherlands Trial Register. Research findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NL9437; The Netherlands Trial Register.

Cross-cultural adaptation and validation of the Motivation in Stroke Patients for Rehabilitation Scale in Chinese hospitalized older adults with stroke

OBJECTS

To translate, cross-culturally adapt, and validate the Motivation in Stroke Patients for Rehabilitation Scale (MORE) questionnaire in Chinese hospitalized older adults with stroke.

METHODS

The Chinese version of the MORE was produced following Brislin's guidelines. The psychometric properties of the MORE were evaluated among 420 eligible patients.

RESULTS

The Cronbach's alpha coefficient of the Chinese version of the MORE scale was 0.983, and the content validity index (S-CVI) was 0.94, with good reliability. Exploratory factor analysis showed a single-factor structure that explained 78.01% of the total variance, and the confirmatory factor analysis model had a good fit index (X²/df=2.97; NFI =0.93; CFI=0.96; TFI=0.95; IFI=0.96).

CONCLUSION

The MORE presented acceptable validity and reliability and could be used in Chinese hospitalized older adults with stroke.

Design, development, and use of conversational agents in rehabilitation for adults with brain-related neurological conditions: a scoping review

OBJECTIVE

The objective of this review was to identify how conversational agents are designed and used in rehabilitation for adults with brain-related neurological conditions.

INTRODUCTION

Adults with brain-related neurological conditions experience varied cognitive and functional challenges that can persist long term. However, rehabilitation services are time- and resource-limited, and novel rehabilitation approaches are warranted. Conversational agents provide a human-computer interface with which the user can converse. A conversational agent can be designed to meet specific user needs, such as rehabilitation and support.

INCLUSION CRITERIA

Studies focused on the design and use of conversational agents for rehabilitation for people aged 18 years or older with brain-related neurological conditions were considered for inclusion. Eligible publication types included peer-reviewed publications (quantitative, qualitative, and/or mixed methods study designs; research protocols; peer-reviewed expert opinion papers; clinical studies, including pilot trials; systematic or scoping reviews), full conference papers, and master's or PhD theses. Eligible types of research included prototype development, feasibility testing, and clinical trials.

METHODS

Online databases, including MEDLINE, Scopus, ProQuest (all databases), Web of Science, and gray literature sources were searched with no date limit. Only English publications were considered due to a lack of resourcing available for translations. Title and abstract screening and full-text review were conducted by two independent reviewers. Data extraction was shared by three independent reviewers. The data extraction instrument was iteratively refined to meet the requirements of all included papers, and covered details for technological aspects and the clinical context. Results are presented narratively and in tabular format, with emphasis on participants, concept and context, and data extraction instrument components.

RESULTS

Eleven papers were included in the review, which represented seven distinct conversational agent prototypes. Methodologies included technology description (n = 9) and initial user testing (n = 6). The intended clinical cohorts for the reported conversational agents were people with dementia (n = 5), Parkinson disease (n = 2), stroke (n = 1), traumatic brain injury (n = 1), mixed dementia and mild cognitive impairment (n = 1), and mixed dementia and Parkinson disease (n = 1). Two studies included participants who were healthy or otherwise from the general community. The design of the conversational agents considered technology aspects and clinical purposes. Two conversational agent prototypes incorporated a speaking humanoid avatar as reported in five of the papers. Topics of conversation focused on subjects enjoyable to the user (life history, hobbies, where they lived). The clinical purposes reported in the 11 papers were to increase the amount of conversation the user has each day (n = 4), reminiscence (n = 2), and one study each for anxiety management and education, Parkinson disease education, to obtain and analyze a recording of the user's voice, to monitor well-being, and to build rapport before providing daily task prompts. One study reported clinician oversight of the conversational agent use. The studies had low sample sizes (range: 1-33). No studies undertook effectiveness testing. Outcome measures focused on usability, language detection and production, and technological performance. No health-related outcomes were measured. No adverse events were reported, and only two studies reported safety considerations.

CONCLUSIONS

Current literature reporting the design and use of conversational agents for rehabilitation for adults with brain-related neurological conditions is heterogeneous and represents early stages of conversational agent development and testing. We recommend, as per our customized data extraction instrument, that studies of conversational agents for this population clearly define technical aspects, methodology for developing the conversation content, recruitment methods, safety issues, and requirements for clinician oversight.

Development and validation of new evaluation scale for measuring stroke patients' motivation for rehabilitation in rehabilitation wards

OBJECTIVE

This study aimed to develop the Motivation in stroke patients for rehabilitation scale (MORE scale), following the Consensus-based standards for the selection of health measurement instruments (COSMIN).

METHOD

Study participants included rehabilitation professionals working at the convalescent rehabilitation hospital and stroke patients admitted to the hospital. The original MORE scale was developed from an item pool, which was created through discussions of nine rehabilitation professionals. After the content validity of the scale was verified using the Delphi method with 61 rehabilitation professionals and 22 stroke patients, the scale's validity and reliability were examined for 201 stroke patients. The construct validity of the scale was investigated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and item response theory analysis. Cronbach's alpha confirmed its internal consistency. Regarding convergent, discriminant, and criterion validity, Spearman's rho was calculated between the MORE scale and the Apathy Scale (AS), Self-rating Depression Scale (SDS), and Visual Analogue Scale (VAS), which rates the subjective feelings of motivation.

RESULTS

Using the Delphi method, 17 items were incorporated into the MORE scale. According to EFA and CFA, a one-factor model was suggested. All MORE scale items demonstrated satisfactory item response, with item slopes ranging from 0.811 to 2.142, and item difficulty parameters ranging from -3.203 to 0.522. Cronbach's alpha was 0.948. Regarding test-retest reliability, a moderate correlation was found between scores at the beginning and one month after hospitalization (rho = 0.612. p < 0.001). The MORE scale showed significant correlation with AS (rho = -0.536, p < 0.001), SDS (rho = -0.347, p < 0.001), and VAS (rho = 0.536, p < 0.001), confirming the convergent, discriminant, and criterion validity, respectively.

CONCLUSIONS

The MORE scale was verified as a valid and reliable scale for evaluating stroke patients' motivation for rehabilitation.

Motivation for Rehabilitation in Patients With Subacute Stroke: A Qualitative Study

Background: Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation.

Purpose: This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences.

Method: Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged < 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research.

Results: Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients.

Conclusions: Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

Individuals' Intention to Engage in Outpatient Cardiac Rehabilitation Programs: Prediction Based on an Enhanced Model

Motivation is an important factor in encouraging individuals to attend rehabilitation and underpins many approaches to engagement. The aims of this study were to develop an accurate model able to predict individual intention to engage in outpatient cardiac rehabilitation (CR) programs based on the first stage of the Model of Therapeutic Engagement integrated into a socio-environmental context. The cross-sectional study in the cardiology ward of an Australian hospital included a total of 217 individuals referred to outpatient CR. Through an ordinal logistic regression, the effect of random forest (RF)-selected profile features on individual intention to engage in outpatient CR was explored. The RF based on the conditional inference trees predicted the intention to engage in outpatient CR with high accuracy. The findings highlighted the significant roles of individuals' 'willingness to consider the treatment', 'perceived self-efficacy' and 'perceived need for rehabilitation' in their intention, while the involvement of 'barriers to engagement' and 'demographic and medical factors' was not evident.

Scoping Review on the Concept of Patient Motivation and Practical Tools to Assess it

Background:

In this scoping review, the concept of patients' motivation and the tools that have been designed to measure this concept in clinical settings are presented.

Materials and Methods:

Arksey and O'Malley's framework was used in conducting the current scoping review. Google Scholar, PubMed, Scopus, and Web of Science databases were searched for relevant English articles published between January 1995 and January 2020 using the keywords motivation and tool, and their synonyms. Out of 2820 articles, 34 articles were chosen and were entered into the final analysis. Definitions of patients' motivation were determined using Kyngäs et al., content analysis method.

Results:

The findings showed that new tools had been developed in 38% of the studies and other studies had revised or translated existing questionnaires. Moreover, 62% of the tools were used to measure patient motivation in mental disorders. Most of the studies did not clearly define the concept of patient motivation in the clinical environment. The findings of content analysis outlined the 3 categories of motivation determinant factors, decisions, and behaviors that determine overall levels of motivations and its consequences.

Conclusions:

Motivation is a dynamic concept and is a result of internal and external motives that lead to decisions and behaviors. There are limited tools for measuring motivation in clinical settings. This addresses the need to design specific tools in various diseases, especially chronic diseases. By the concept defined in this study, it is possible to design a short tool with general application that can be used in all diseases.

The Process of Patient Engagement in Outpatient Cardiac Rehabilitation Programs

The primary aim of this study was to test the causal structure of the model of therapeutic engagement (MTE) for the first time, to examine whether the model assists in understanding the process of patient engagement in cardiac rehabilitation (CR) programs. This study used a prospective design, following up patients from the Gold Coast University Hospital Cardiology ward who attended Robina Cardiac Rehabilitation Clinic. A structural equation model of the interactions among the proposed variables within the three stages of the MTE (intention to engage in CR programs, CR initiation, and sustained engagement) revealed significant relationships among these variables in a dataset of 101 patients who attended a CR program. However, no relationship was discerned between outcome expectancies and patient intention to engage in CR. Patients’ willingness to consider the treatment also mediated the relationship between perceived self-efficacy and patient intention to engage in CR. These findings help clarify the process proposed by Lequerica and Kortte (2010) in the context of patient engagement in CR programs. The findings also reveal information on how patients engage in CR programs. Importantly, this provides new information for healthcare providers, enabling them to more effectively engage patients according to their stage of engagement.

Assessing Patient Motivation for Treatment: A Systematic Review of Available Tools, Their Measurement Properties, and Conceptual Definition

BACKGROUND AND PURPOSE

Motivation is often reported by clinicians and researchers as a key factor related to treatment and health outcomes. This systematic review aims to (a) Identify and critically appraise tools that measure patient motivation for treatment and (b) determine how these tools define and evaluate motivation.

METHODS

Library databases and the search engine Google Scholar were examined. Identified tools measuring patient motivation for treatment and reported measurement properties were selected.

RESULTS

14 peer-reviewed articles covering 12 different tools made the final selection. Quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and a new measure checklist. Reliability evidence was predominantly estimated using internal consistency; validity evidence was limited, and responsiveness was seldom examined. Overall, quality ratings were poor or inadequately reported and serious methodological limitations were identified. A lack of conceptual foundation quality ratings as tools did not apply a theory related to motivation or have a clear definition of the construct of patient motivation.

CONCLUSIONS

A significant gap exists of available tools with adequate measurement properties that use relevant theoretical frameworks.

Feasibility of Aerobic Exercise in the Subacute Phase of Recovery From Traumatic Brain Injury: A Case Series

BACKGROUND AND PURPOSE

Aerobic exercise is as important for individuals with traumatic brain injury (TBI) as for the general population; however, the approach to aerobic training may require some adaptation. The objective of the trial program was to examine the feasibility of introducing aerobic physical exercise programs into the subacute phase of multidisciplinary rehabilitation from moderate to severe TBI, which includes computerized cognitive training.

CASE DESCRIPTION

Five individuals undergoing inpatient rehabilitation with moderate or severe TBIs who also have concomitant physical injuries. All of these individuals were in the subacute phase of recovery from TBIs.

INTERVENTION

An 8-week progressive aerobic physical exercise program. Participants were monitored to ensure that they could both adhere to and tolerate the exercise program. In addition to the physical exercise, individuals were undergoing their standard rehabilitation procedures that included cognitive training. Neuropsychological testing was performed to gain an understanding of each individual's cognitive function.

OUTCOMES

Participants adhered to both aerobic exercise and cognitive training. Poor correlations were noted between heart rate reserve and ratings of perceived effort. Two minor adverse events were reported.

DISCUSSION

Despite concomitant physical injuries and cognitive impairments, progressive aerobic exercise programs seem feasible and well tolerated in subacute rehabilitation from moderate to severe TBI. Findings highlight the difficulty in measuring exercise intensity in this population.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A235).

Motivation in rehabilitation and acquired brain injury: can theory help us understand it?

Background: In acquired brain injury (ABI) populations, low motivation to engage in rehabilitation is associated with poor rehabilitation outcomes. Motivation in ABI is thought to be influenced by internal and external factors. This is consistent with Self-determination Theory, which posits that motivation is intrinsic and extrinsic. This paper discusses the benefit of using Self-determination Theory to guide measurement of motivation in ABI. Methods: Using a narrative review of the Self-determination Theory literature and clinical rehabilitation research, this paper discusses the unique role intrinsic and extrinsic motivation has in healthcare settings and the importance of understanding both when providing rehabilitation in ABI. Results: Based on the extant literature, it is possible that two independently developed measures of motivation for ABI populations, the Brain Injury Rehabilitation Trust Motivation Questionnaire-Self and the Motivation for Traumatic Brain Injury Rehabilitation Questionnaire, may assess intrinsic and extrinsic motivation, respectively. Conclusion: Intrinsic and extrinsic motivation in ABI may be two equally important but independent factors that could provide a comprehensive understanding of motivation in individuals with ABI. This increased understanding could help facilitate behavioural approaches in rehabilitation. Implications for Rehabilitation Conceptualization of motivation in ABI would benefit from drawing upon Self-determination Theory. External factors of motivation such as the therapeutic environment or social support should be carefully considered in rehabilitation in order to increase engagement. Assessing motivation as a dual rather than a global construct may provide more precise information about the extent to which a patient is motivated.

Psychometric properties of the awareness questionnaire, patient competency rating scale and Dysexecutive Questionnaire in patients with acquired brain injury

OBJECTIVE

Lack of self-awareness of impairments is common after acquired brain injury (ABI). We evaluated the psychometric properties of three commonly used instruments for measuring self-awareness: Awareness Questionnaire (AQ), Patient Competency Rating Scale (PCRS) and Dysexecutive questionnaire (DEX).

METHOD

We recruited 105 patients with ABI and their relatives. We determined feasibility, responsiveness, test- retest reliability, internal consistency, and construct validity of AQ, PCRS and DEX.

RESULTS

No floor or ceiling effects were present. Total scale scores showed sufficient responsiveness: effect sizes were moderate to large (.57-.85); test-retest reliability was sufficient for patient forms (.75- .88) but mixed for relative forms (.60-.66). Internal consistency was good (.80-.89). Construct validity results confirmed a three-factor structured AQ and a four-factor structured PCRS. A two-facture structure was found for DEX patient forms; a three-factor structure was found for relative forms.

CONCLUSION

Overall, the total scale scores of patient forms of all questionnaires demonstrated sufficient psychometric properties. Psychometric properties of subscales are questionable. We could not replicate the factor structures of AQ, PCRS and DEX: the items within subscales differed with previous findings. Additional research into the test-retest, inter-rater reliability and responsiveness of relative and clinician forms is required.