Abstract
Objective
Various strategies are used to motivate individuals with stroke during rehabilitation. However, how physical therapists select the motivational strategies that they use for each individual is yet to be established. Therefore, this study aimed to explore how physical therapists use different motivational strategies for individuals in stroke rehabilitation programs.
Methods
A criterion sample of 15 physical therapists who have worked in rehabilitation for over 10 years and were interested in an individual’s motivation participated in one-on-one semi-structured online interviews. The interviews explored their perspectives and experiences regarding the motivational strategies used depending on each individual’s condition. The collected data were analyzed with thematic analysis.
Results
A total of 9 themes emerged from the data upon thematic analysis and inductive coding. Participants used different strategies to encourage individuals’ active participation in physical therapy depending on (1) their mental health, (2) their physical difficulties, (3) their level of cognitive function, (4) their personality, (5) their activities and participation, (6) their age, (7) their human environment, and (8) the type of rehabilitation service where the individual underwent treatment. For example, in cases where an individual lost self-confidence, participants offered practice tasks that the individual could achieve with little effort to make them experience success. The interviews also revealed (9) motivational strategies used regardless of the individual’s condition. For instance, patient-centered communication was used to build rapport with individuals, irrespective of their condition.
Conclusion
This qualitative study suggests that physical therapists use different strategies depending on the individual’s mental health conditions, physical problems, level of cognitive function, personality, activities and participation, age, human environment, and the type of rehabilitation service where the individual undergoes treatment to motivate individuals with stroke during physical therapy.
Impact
The findings of this study can provide experience-based recommendations regarding the selection of motivational strategies for stroke rehabilitation.
Keywords: Patient-Centered Care, Physical Therapists, Psychotherapy, Rehabilitation, Stroke
Introduction
Physical activity is any bodily movement produced by skeletal muscles that results in energy expenditure, whereas exercise is defined as a subset of physical activity that is planned, structured, and repetitive with a final or intermediate objective of improving or maintaining physical fitness.1,2 Physical activity and exercise help these individuals improve motor and cognitive impairments, increase independence in activities of daily living, and reduce the risk of stroke recurrence.3,4 However, physical inactivity after a stroke is highly prevalent.5,6
Motivation, “mental function that produces the incentive to act; the conscious or unconscious driving force for action,”7 is an essential factor for active participation in physical activity and exercise after stroke.2,8 High adherence to a prescribed rehabilitation program is partially attributed to higher motivation,9 which is associated with improved functional recovery after stroke.10–12 Thus, an individual’s motivation is considered to be a determinant of rehabilitation outcome.9,13 For these reasons, physical therapists, who have great potential for promoting physical activity,14 are required to have expertise in enhancing motivation in individuals undergoing rehabilitation.
Motivation toward physical activity and exercise is a fluid condition rather than a static quality.15 Social factors in combination with the individual’s personality or clinical characteristics are considered possible determinants of motivation for rehabilitation.2,8,15,16 For example, cognitive and physical impairments may decrease motivation,9,15,17 whereas self-confidence and support from family are perceived motivators for physical activity.15,18,19 The addition of motivational strategies to physical therapy has also been reported to increase adherence to exercise, positively affect long-term exercise behavior, improve self-confidence, and reduce levels of activity limitation in individuals with various chronic diseases.20 We previously reported that rehabilitation professionals used a range of motivational strategies for stroke rehabilitation based on a comprehensive consideration of the individuals’ health-related information, suggesting that they use individual-tailored motivational strategies.21,22 However, to our knowledge, it remains to be established how physical therapists select their motivational strategies for each individual. Rehabilitation professionals tend to acquire skills to motivate individuals through their clinical experience.21 Therefore, qualitative exploration of the perspectives and experiences of expert physical therapists in motivating individuals with stroke may help to better facilitate their participation in rehabilitation.
Qualitative research has been employed to explore factors influencing motivation in individuals with stroke.8,15 Qualitative methods highlight the opinions of individuals to gain a deeper understanding of their perspectives and experiences within personal contexts that quantitative studies cannot explore or address.23 Therefore, qualitative methods may be highly beneficial for understanding how physical therapists tailor motivational strategies toward each individual with a stroke. This qualitative study aimed to explore how physical therapists use different motivational strategies for individuals in stroke rehabilitation.
Methods
Design
In our qualitative study, we used semi-structured interviews, which allow the interviewer and interviewee to diverge to pursue an idea or response in greater detail.23 We followed the Standards for Reporting Qualitative Research guidelines.24 The study was approved by the Institutional Review Board at Shinshu University (approval number: 4830) and at the Hamamatsu University School of Medicine (approval number: 20–206). In addition, all participants provided written informed consent before enrolment in the study. Furthermore, the study was conducted according to the Declaration of Helsinki of 1964, as revised in 2013.
Participants
A criterion sampling technique was used to select participants.25,26 To obtain rich and thick data, researchers need to recruit knowledgeable participants who can articulate and reflect on the research topic.25 Thus, participants in this study were expected to be physical therapists with expertise in stroke rehabilitation and great interest in motivation strategies. To the best of our knowledge, a uniform definition of experts in physical therapy for individuals with stroke has not been established. Therefore, in this study, we defined physical therapists with at least 10 years of expertise in stroke rehabilitation as experts. To recruit participants, we first selected 66 potential physical therapists with at least 10 years of clinical experience from those who participated in our previous studies on motivational strategies for stroke rehabilitation.21,22 Email invitations were sent to 3 or 4 potential participants every week while evaluating whether data saturation was reached. The potential participants to whom we sent the invitations were determined by computer-generated random numbers. Once interest was confirmed, participants were provided with an information sheet detailing the purpose of the study and information regarding data confidentiality alongside an informed consent form to be completed prior to the interview. Participants were informed that they could withdraw from the study at any time. They were also reimbursed for their time with a 5000-yen gift card (approximately U.S. $45.00). The reimbursement for participants was cited in the project description submitted to the ethical committee.
The final sample size was determined by the principle of data saturation.27,28 Data saturation was considered as the point at which similar responses were elicited in the interviews with repeating rather than novel ideas. Qualitative studies require a minimum sample size of at least 12 participants to reach data saturation.28 Assuming that the data from ~20% of participants would be excluded from the analysis, we aimed to recruit a total of 15 participants.
Data Collection
The interviews were conducted from October 2020 to January 2021. An interview guide was developed based on our previous studies.21,22 Prior to data collection, we conducted a pilot test to confirm that the interview guide was clear, understandable, and capable of answering the research questions.23 The pilot test was conducted with 3 physical therapists who had <10 years of clinical experience, resulting in minor changes to wording.
In this study, motivational strategy was defined as concrete tactics, techniques, or approaches to orient rehabilitation of individuals.22 The definitions of motivation and motivational strategy were explained to participants prior to the interview to provide a common understanding of the terms. The interviewer orally asked participants to answer questions based on their clinical experience and explained that there were no right or wrong answers to the interview questions. The interviews began with general questions about the most impressive experience of motivating an individual during rehabilitation, followed by specific questions about which motivational strategies participants used based on the individual’s condition (Tab. 1). In the specific questions, we comprehensively investigated the types of conditions of the individual that participants thought needed to be motivated based on the model of the International Classification of Functioning, Disability, and Health: Health condition, body functions and structures, activities and participation, personal factors, and environmental factors.
Table 1.
Semi-Structured Interview Guidea
| Topic | Question |
|---|---|
| General questions |
|
| Motivational strategies to be used in consideration of health conditions of individuals |
|
| Motivational strategies to be used in consideration of body functions and structures of individuals |
|
| Motivational strategies to be used in consideration of activities and participation of individuals |
|
| Motivational strategies to be used in consideration of personal factors of individuals |
|
| Motivational strategies to be used in consideration of the environmental factors of individuals |
|
ICF = International Classification of Functioning, Disability, and Health.
Each interview was conducted one-on-one by 1 of 2 interviewers, K.O. and K.S., who were physical therapists with over 10 years of clinical experience, and video-conferencing software (Zoom, Zoom Video Communications Inc., San Jose, CA, USA) was used due to Coronavirus Disease 2019 (COVID-19) restrictions. Video-conferencing interviews were the closest alternative to face-to-face interviews and allowed participants to join the interview from a distance. To ensure privacy, interviewers and interviewees participated in the interview in a private room. Considering the psychological burden of participants, interviewers told participants that the interview could be stopped immediately when any psychological burden arose during the interview. Interviews lasted from 90 to 120 minutes. During and after each interview, the interviewer ensured that the interviewee was not distressed by asking about their distress as appropriate and observing the interviewee’s behavior.
Data Analysis
All interviews were digitally recorded using the recording function of the video-conferencing software and transcribed verbatim by an external provider of transcription services (Tokyo Hanyaku Co., Ltd., Tokyo, Japan). The collected data were analyzed with thematic analysis involving 6 stages: Becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report.29 The first author generated the initial codes. Furthermore, the first and second authors made subthemes and themes through repeated discussion until a consensus was reached. The third and fourth authors served as methodological auditors to examine the credibility of the conceptual interpretation of the original data.30 To protect the identities of participants, their names were replaced with pseudonyms. In quotations, we used an ellipsis mark to indicate the omitted words. Square brackets were used to supply words omitted by the speaker. A qualitative data management software (MAXQDA 2020, VERBI Software, Berlin, Germany) was used to analyze and organize the data.
Role of the Funding Source
The funders played no role in the design, conduct, or reporting of this study.
Results
Flow of Participants Through the Study
We sent email invitations to a total of 48 potential participants to recruit 15 participants as required for data saturation; as there was no response from 33 of them. The characteristics of participants are shown in Table 2 and are described in more detail in the Supplementary Material. Thirteen participants were males, and their mean years of clinical experience was 14.9 years (standard deviation 4.0). All participants worked at different institutions in Japan. Thirteen participants had worked in a skilled nursing rehabilitation for individuals with subacute stroke, 8 of whom worked there at the time of the interviews (Suppl. Material). In addition, 8 participants had a personal relationship with their respective interviewers.
Table 2.
Characteristics of Participants
| Variable | Value |
|---|---|
| Sex, no. (%) Reported as male Reported as female |
12 (80) 3 (20) |
| Clinical experience, y, mean (SD) | 14.9 (4.0) |
| Current primary practice setting | |
| Phase of stroke recovery of the individuals, no. (%) Acute Subacute Chronic, no. (%) |
5 (33) 9 (60) 3 (20) |
| Rehabilitation service, no (%) In-hospital Skilled nursing Homecare Out-of-hospital |
5 (33) 8 (53) 2 (13) 0 (0) |
| Other practice experience | |
| Phase of stroke recovery of the individuals, no. (%) Acute Subacute Chronic |
4 (27) 5 (33) 9 (60) |
| Rehabilitation service, no. (%) In-hospital Skilled nursing Homecare Out-of-hospital |
5 (33) 5 (33) 4 (27) 4 (27) |
Themes
No new ideas/themes were discovered after the 12th interview, indicating that data saturation was reached. Consequently, 9 themes emerged from the data: They are summarized with representative quotes in Table 3 and described below.
Table 3.
Motivational Strategies Used Based on the Condition of the Individuals
| Individual Condition | Motivational Strategya | Representative Quotesb |
|---|---|---|
| Theme 1: Motivational strategies used for individuals with mental health problems | ||
| Individuals with anxiety | Explaining the availability of support from rehabilitation professionals and the possibility of recovery | Kana: I let the individuals know about the support system, that is, that we support them…I’ll also tell them that although it takes time, their symptoms will gradually improve. |
| Individuals with depression | Using cognitive behavioral therapy | Dai: Because he had no cognitive problems…When he had some misconceptions, I corrected his assumptions, and, uh, gave him some advice. |
| Setting goals that are achievable for the individual |
Akira: For example, I prepare an escape route for the individuals…They tend to cling to one goal, even if it is difficult to achieve. I propose several goals that are achievable for the individual. | |
| Theme 2: Motivational strategies for individuals with physical difficulties | ||
| Individuals with fatigue and pain | Taking care of symptoms | Go: I think that fatigue has a negative effect on motivation for rehabilitation. When the individuals get tired easily, I allow them to take frequent breaks. |
| Akira: The individual had no problem with motivation as long as there was no pain. So, I used assistive devices, such as a harness [system]…I made the individual realize, “Oh, this won’t hurt.” | ||
| Individuals with motor impairments | Giving the individual hope for recovery |
Naoto: Of course, it’s good for the individuals to experience that electrical stimulation can move the paralyzed muscles even a little bit. This allows them to participate in their rehabilitation with greater hope for recovery. |
| Theme 3: Motivational strategies used based on the level of cognitive function of the individual | ||
| Individuals with cognitive impairments | Applying the individual’s preferences and lifestyle to practice tasks | Chie: So the individuals don’t feel uncomfortable with physical therapy and exercise…It’s like incorporating the individuals’ interests into their physical therapist programs. |
| Dai: Even when I explain the need for rehabilitation, …it is difficult for them to understand it…I provide them with physical therapist programs related to their lifestyle before the onset of stroke, hobbies, and a role in the family. That’s the point, isn’t it? | ||
| Individuals with preserved cognitive function | Respecting individual’s self-determination | Riku: For these individuals, I encourage them to think about why they have failed and how they can do better. |
| Theme 4: Motivational strategies used in consideration of the personality of the individual | ||
| Individuals with low self-confidence | Allowing the individual to engage in self-training |
Dai: He had difficulty to gain confidence in walking. So, I allowed him to engage in self-training of walking out of the rehabilitation sessions…This seemed to decrease his fear of falling and to increase his self-efficacy. |
| Praise | Riku: Yes, I praise the efforts that the individual has made until now. | |
| Providing practice tasks that are achievable with little effort | Akira: He seemed to have received only difficult training that he could not do since the acute phase. So, he was getting very tired of the training. However, when I set the difficulty level a little lower for him, and selectively provided practice tasks that he could do, well, his acceptance gradually improved. | |
| Individuals with overconfidence | Providing a relatively difficult practice task |
Naoto: If individuals are overconfident [in their performance ability], I would provide them with a difficult task and let them know that they can’t do this by making them experience failure…Thus, I think it is necessary to let them experience failure so that they can think, “Let’s try a little harder.” |
| Individuals with high self-esteem | Making the individual feel superior to other individuals |
Mai: It’s hard to motivate individuals with high self-esteem, isn’t it? I think it is essential to make them feel superior to other individuals, so that they don’t lose their motivation…Once these individuals lose their self-confidence, they won’t accept [their] rehabilitation [programs]. |
| Individuals reluctant to exercise | Emphasized the benefits of exercise | Yukio: Individuals who have diabetes as a comorbidity are less concerned about their own health. This is just my impression [of them]. As they’re not health-conscious, so it’s hard to keep them motivated…Thus, for these individuals, I emphasize the benefits of exercise in the hope of increasing their motivation. |
| Explaining about the negative effects of sedentary lifestyle |
Jun: I give examples such as, “If you lie down all the time, you will lose your physical strength” …I try to explain to them the negative effects [of sedentary lifestyle]. | |
| Theme 5: Motivational strategies used in consideration of the activities and participation of the individual | ||
| Individuals seeking to improve their daily activities and social participation | Providing goal-oriented practice | Mai: Many individuals who have severe limitations in daily activities hope to perform at least toileting activities by themselves...If the practice is related to toileting, they are often willing to engage in it. |
| Chie: If the individual lives on the second floor of an apartment building and has to go up the stairs [to be discharged home], I would tell [the individual], “Well, Let’s become able to climb stairs” and would ask [the individual], “What do you need to do to be able to go up the stairs?” | ||
| Providing positive feedback | Dai: I provide feedback on the individual’s improvements as specifically as possible. For example, “yesterday you could walk 50 meters, and today you could walk 100 meters!” | |
| Theme 6: Motivational strategies used depending on the age of the individual | ||
| Older individuals (aged ≥65 years) | Applying the individual’s preferences and lifestyle to practice tasks | Sora: An aged individual liked to listen to western music on a record player…When I provided him with a practice task related to the operation of a record player, he actively engaged in the practice task…I think it is more important to make the individuals enjoy their rehabilitation than to encourage their efforts for improving their motor function and daily activities. |
| Relatively younger individuals (aged <65 years) | Setting goals related to activities before the onset of stroke | Touma: When trying to motivate a relatively young individual, I set the goals of returning to work or society. |
| Theme 7: Motivational strategies used in consideration of the human environment of the individual | ||
| Individuals with family members | Asking the individual’s family members to assist with daily activities | Itsuki: If it were not for the COVID-19 pandemic, I would involve the individual’s family in the physical therapist process. Specifically, when the family members were present during physical therapy, I asked them to engage in helping the individual walk. |
| Asking the individual’s family members to encourage the individual | Kana: Many individuals seem to be more motivated when being encouraged by their family members than by me. | |
| Setting a goal to reduce the burden on the individual’s family members | Chie: For individuals with family, I would tell them, “Let’s increase the number of activities that you can do on your own, so that you don’t bother your family.” | |
| Theme 8: Motivational strategies used based on the type of rehabilitation service where the individual undergoes treatment | ||
| Individuals in an acute rehabilitation setting | Explaining the existence of support from rehabilitation professionals | Chie: Many of individuals [in acute care ward] are in shock. So, I let them know that we are here to support them. |
| Explaining the possibility of recovery | Go: I think that many individuals in an acute rehabilitation setting have high motivation…They are also worried about their future. So, to maintain their motivation, I explain to them that it takes time for recovery from paresis after stroke. | |
| Providing interventions to improve motor function | Go: I think that interventions to improve motor function is an effective motivational strategy. Especially in the acute stage, individuals seem to be more motivated when they can move their hands or have functional improvements than when they become able to perform any movement. | |
| Individuals in a subacute rehabilitation setting | Explaining treatment plan | Yukio: Because the individuals are highly motivated and have a strong desire to recover…I have to give them a clear explanation of the future treatment plan. |
| Individuals in a chronic rehabilitation setting | Providing physical therapist programs with variation | Akira: [Rehabilitation in] the chronic phase is a battle with the rut…I changed physical therapist programs from day to day to prevent the individuals from getting bored. |
| Theme 9: Motivational strategies used regardless of the condition of the individual | ||
| All individuals engaging in physical therapy after stroke | Engaging in enjoyable conversation with the individual | Kana: I have conversations that entertain my individuals. I hope them to enjoy spending time with me. I think it is important to build such a good relationship with individuals to motivate them during rehabilitation. |
| Patient-centered communication | Dai: Basically, I keep in mind to accept the individuals’ complaints without denying them. If I did not, I would lose the individuals’ trust. | |
| Jun: When talking to the individual, I have tried to be as polite as possible to male individuals…Female individuals tend to prefer to be treated in a friendly rather than polite manner. | ||
| Providing opportunities to meet other individuals | Touma: Since the COVID-19 pandemic…individuals have fewer opportunities to meet other individuals…Some individuals were motivated when I showed them other individuals who were engaging in rehabilitation. As I realized only after the onset of the COVID-19 pandemic, the opportunities to see other individuals’ efforts and to communicate with other individuals, such as a group rehabilitation, may promote the individual’s engagement in rehabilitation. | |
a The motivational strategies are arranged in alphabetical order for each theme.
b An ellipsis mark indicates the omitted words. Square brackets are used to supply words omitted by the speaker.
Participants assessed the individual’s conditions influencing their choices of motivational strategies based on information obtained from clinical observations, such as the individual behavior and symptoms, and that in the medical records. However, mental health problems, physical difficulties, cognitive function, and personality described below were assessed with more emphasis on the individual’s behavior and symptoms rather than information obtained from the medical records. The participant Mai stated,
I anticipate the motivational strategies needed for the individual from the information in the medical record. However, ultimately, I determine the appropriate strategies based on the individual’s behavior.
Theme 1: Motivational Strategies Used for Individuals With Mental Health Problems
Participants thought that mental health problems, such as anxiety and depression, affected an individual’s motivation for physical therapy. The participant Dai used cognitive behavioral therapy to motivate individuals with depression. He gave such individuals advice to correct their assumptions and misconceptions. The participant Akira also tried to increase their motivation by setting goals that were achievable for them:
For example, I prepare an escape route for the individuals…They tend to cling to one goal, even if it is difficult to achieve. I propose several goals that are achievable for the individual.
In addition, if individuals were concerned about their future, the participant Kana provided them with information on the availability of support from rehabilitation professionals and the possibility of recovery to reduce their anxiety:
I let the individuals know about the support system, that is, that we support them…I’ll also tell them that although it takes time, their symptoms will gradually improve.
Thus, participants tried to encourage the active participation of the individuals in the rehabilitation program by reducing their depressive symptoms and anxiety.
Theme 2: Motivational Strategies for Individuals With Physical Difficulties
The analysis revealed that participants used different motivational strategies for individuals with fatigue, pain, and motor impairment. In cases where individuals presented fatigue and pain, participants tried to maintain their motivation by addressing these symptoms, such as by taking frequent breaks and recommending the use of assistive devices. In addition, for individuals with motor impairment, some participants tried to give individuals hope for recovery by using therapeutic electrical stimulation. The participant Naoto stated,
Of course, it’s good for the individuals to experience that electrical stimulation can move the paralyzed muscles even a little bit. This allows them to participate in their rehabilitation with greater hope for recovery.
Theme 3: Motivational Strategies Used Based on the Level of Cognitive Function of the Individual
Participants thought that when individuals could not understand the importance of practice and exercise due to cognitive impairment, it would be difficult to encourage their participation in physical therapist programs. Thus, participants tried to prevent the individuals from being reluctant to participate in their physical therapy by providing rehabilitation programs related to their preferences and lifestyle before the onset of stroke. In contrast, for individuals with preserved cognitive function, the participant Riku respected their self-determination and provided them with the opportunity to determine for themselves how to solve their problems.
Theme 4: Motivational Strategies Used in Consideration of the Personality of the Individual
Participants used different motivational strategies depending on the degree of self-confidence of the individual. For individuals with low self-confidence, practice tasks achievable with little effort were offered to allow them to experience success. In addition, allowing individuals to engage in self-training and praise was considered effective in increasing self-confidence. In contrast, some participants mentioned that individuals with overconfidence needed to experience failure to understand the necessity of practice. Thus, they provided these individuals with a relatively difficult practice task. Highly educated individuals and those with a professional background such as the president of a company or a university professor were thought to tend to have higher self-esteem. To motivate such individuals, the participant Mai emphasized the importance of making them feel superior to other individuals:
It’s hard to motivate individuals with high self-esteem, isn’t it? I think it is essential to make them feel superior to other individuals, so that they don’t lose their motivation…Once these individuals lose their self-confidence, they won’t accept [their] rehabilitation [programs].
In motivating individuals who are reluctant or refuse to participate in physical therapist programs, participants tried to make them understand the necessity of physical therapy. For example, participants thought that individuals with comorbid diabetes mellitus tended to be less willing to engage in exercise therapy, because many of them were not health-conscious and did not like to exercise by nature. To motivate individuals who were reluctant to exercise, participants emphasized the benefits of exercise to them. In addition, Jun explained the negative effects of a sedentary lifestyle:
I give examples such as, “If you lie down all the time, you will lose your physical strength”…I try to explain to them the negative effects [of sedentary lifestyle].
Theme 5: Motivational Strategies Used in Consideration of the Activities and Participation of the Individual
For individuals seeking to improve their daily activities and social participation, participants provided goal-oriented practice tasks to enhance their adherence to physical therapist programs. For example, Mai reported,
Many individuals who have severe limitations in daily activities hope to perform at least toileting activities by themselves...If the practice is related to toileting, they are often willing to engage in it.
In addition, if individuals will be discharged to their homes, participants provided the individuals with practice tasks taking into consideration their home environment. Furthermore, positive feedback was used to help individuals be aware of their improvements.
Theme 6: Motivational Strategies Used Depending on the Age of the Individual
Compared with relatively younger individuals (aged <65 years), older individuals (aged ≥65 years) were thought to have less adherence to rehabilitation programs because of giving up on recovery and age-related physical weaknesses. Participants prioritized making their physical therapy enjoyable rather than encouraging their efforts. In contrast, for relatively younger individuals, participants believed that providing practice tasks to help them return to work could increase individual adherence to physical therapist programs.
Theme 7: Motivational Strategies Used in Consideration of the Human Environment of the Individual
For individuals with family members, support from their family, such as encouragement and assistance with daily activities, was considered an effective motivator. Some participants stated that setting a goal of reducing the burden on family members could encourage their participation in physical therapist programs.
Theme 8: Motivational Strategies Used Based on the Type of Rehabilitation Service Where the Individual Undergoes Treatment
Participants varied their motivational strategies depending on the different rehabilitation services where individuals underwent treatment, such as acute, subacute, and chronic rehabilitation settings. Some participants thought that individuals in an acute stroke rehabilitation setting were depressed or anxious. As mentioned above as a motivational strategy for individuals with anxiety, participants explained the availability of support from rehabilitation professionals and the possibility of functional recovery to these individuals. In addition, the participant Go stated that especially for individuals with acute stroke, interventions to improve motor function were an effective motivational strategy. The participant Yukio mentioned that individuals with subacute stroke, who were admitted to a skilled nursing rehabilitation hospital, were more motivated than those in acute or chronic rehabilitation settings. He emphasized the importance of explaining his treatment plan to maintain their proactiveness. Furthermore, participants felt that physical therapist programs in a chronic rehabilitation setting tended to make activities habitual and uninteresting. Akira tried to prevent the individuals from getting bored by providing variations of physical therapist programs.
Theme 9: Motivational Strategies Used Regardless of the Condition of the Individual
The interviews revealed some motivational strategies commonly used regardless of the individual’s condition. Participants mentioned the importance of building a rapport with individuals to motivate them during physical therapy. Patient-centered communication, which included eliciting the individual’s agenda with open-ended questions, not interrupting the individual, and engaging in focused active listening,31 seemed to be used to establish a relationship of trust with the individuals. Engaging in enjoyable conversations with the individuals was also thought to help build a rapport with them.
Some participants thought that the opportunities to interact with other individuals might promote the individual’s engagement in physical therapy. Touma stated,
Since the COVID-19 pandemic…individuals have fewer opportunities to meet other individuals…Some individuals were motivated when I showed them other individuals who were engaging in rehabilitation. As I realized only after the onset of the COVID-19 pandemic, the opportunities to see other individuals’ efforts and to communicate with other individuals, such as a group rehabilitation, may promote the individual’s engagement in rehabilitation.
Discussion
To the best of our knowledge, this qualitative research is the first to describe the motivational strategies used for physical therapy according to the condition of the individuals after a stroke. Consistent with our previous studies,21,22 participants decided which motivational strategies to use based on a comprehensive consideration of the individual’s health-related information, including their health condition, body functions and structures, activities and participation, personal factors, and environmental factors. Our results suggest that physical therapists use different motivational strategies for each individual based on their mental health conditions, physical difficulties, level of cognitive function, personality, activities and participation, age, human environment, and the type of rehabilitation service where the individual undergoes treatment. The qualitative findings provide a deeper understanding of the selection of motivational strategies in stroke rehabilitation.
Participants selected the appropriate motivational strategy considering the cause of an individual’s lack of motivation. For example, anxiety hampered the stroke rehabilitation effort and prevented individuals from returning to their usual activities.32 Participants tried to reduce individuals’ anxiety about their future by providing information on the availability of support programs from rehabilitation professionals and the possibility of recovery. Information provision by involving individuals or providing reinforcement may reduce anxiety in individuals with stroke, although the effect size is small.33 Physical difficulties, cognitive impairment, and advanced age have also been reportedly associated with lower adherence to physical activity after stroke.8,17,34,35 Participants tried to motivate individuals with these conditions by respecting each individual’s values, preferences, experiences, and self-determination. The strategies are tailored to the individual to promote and support patient-centered care. The concept of patient-centered care is defined as “care provision that is consistent with the values, needs, and desires of patients and is achieved when clinicians involve patients in healthcare discussions and decisions.”36,37 Older population is a priority target group to receive and benefit from patient-centered care because older individuals are more likely to have complex care needs than younger individuals.38 Models of patient-centered care have been successfully translated into practice for older adults with chronic conditions and functional impairment, including individuals with stroke39 and those with dementia.40 Thus, the use of different motivational strategies according to the individual’s condition appears to enhance adherence and improve rehabilitation outcomes.
Participants also used different motivational strategies based on the type of rehabilitation service, such as acute, subacute, and chronic rehabilitation settings. The rehabilitation adherence of individuals with stroke has been reported to be a dynamic behavioral process that continuously changes along a time course, with a regular pattern of an S-curve.41 During the period between the 1st and 6th weeks after stroke, many people with stroke are hospitalized in the intensive care unit or rehabilitation department and experience significant functional recovery; therefore, their adherence levels increase rapidly during this period. During the 6th to 21st week after stroke, they are discharged from the hospital and returned to their homes, while their adherence levels to rehabilitation training decrease relatively slowly. Furthermore, after the 21st week after the stroke, when the effects of rehabilitation are not as obvious as before, no drastic fluctuation of rehabilitation adherence occurs. Thus, participants in this study may vary the motivational strategies they used according to these changes in adherence to rehabilitation training after stroke.
The interviews also helped to identify motivational strategies commonly applied to all individuals undergoing physical therapy after stroke, regardless of the individual’s condition. The interviews suggested that a rapport between therapists and individuals was essential to enhance an individual’s active participation in physical therapy. Establishing a collaborative partnership between the therapist and the individual is also a patient-centered intervention.39 Danzl et al42 reported 4 strategies to build rapport and trust as follows: (1) Spending time with the individuals without rushing them; (2) developing a deeper understanding of the individuals; (3) using a sense of humor when appropriate; and (4) showing compassion, empathy, and respect. Listening to the individual while refraining from interrupting, understanding the individual’s perspective, and expressing empathy are key features of patient-centered communication.31 A sense of humor contributes to making the individual enjoy rehabilitation. Thus, patient-centered communication and engaging in enjoyable conversation used by participants in this study may have been used to effectively establish a relationship of trust with the individual. Moreover, we found that providing opportunities for individuals to interact with each other effectively motivates individuals for rehabilitation, irrespective of their condition. Interacting with other individuals, such as watching other individuals’ efforts and communicating with other individuals, has been shown to be a perceived motivator for physical activity in individuals with stroke.8,15 However, as participant Touma mentioned, the opportunities for individuals to interact with each other have diminished since the onset of the COVID-19 pandemic. If the COVID-19 pandemic continues, it will become increasingly important to provide an environment that allows individuals to safely interact with each other.
Limitations
This study has several limitations. First, most of the participants had experience working in a skilled nursing rehabilitation center for individuals with subacute stroke. Thus, the perspectives and experiences of motivating individuals in a subacute rehabilitation setting might be overstated in the data. To minimize this sampling bias, we recommended that further studies stratify participants by the individual’s phase of stroke recovery in which they most frequently worked and the rehabilitation services where they worked, such as in-hospital, out-of-hospital, and homecare rehabilitation. Second, this study cannot be generalized to physical therapist settings for a population with conditions other than stroke. Nevertheless, we have previously reported that patients’ choices regarding the most important motivational factors for rehabilitation were not significantly different between individuals with stroke and those with fractures.43 Further qualitative studies in physical therapist settings for individuals with other conditions, such as orthopedic and visceral disorders, would improve the external validity of our findings. Finally, we did not explore how physical therapists with <10 years of clinical experience use different motivational strategies. Thus, future studies are needed in this regard.
Conclusion
This qualitative study suggests that physical therapists use different strategies depending on the individual’s mental health conditions, physical problems, level of cognitive function, personality, activities and participation, age, human environment, and the type of rehabilitation service where the individual undergoes treatment to motivate individuals with stroke during physical therapy. These findings provide an experience-based recommendation for selecting motivational strategies in stroke rehabilitation.
Supplementary Material
Acknowledgments
The authors thank Anna from Editage Group (www.editage.jp) for editing a draft of this manuscript.
Contributor Information
Kazuaki Oyake, Department of Physical Therapy, School of Health Sciences, Shinshu University, Nagano, Japan.
Keita Sue, Department of Rehabilitation, Kakeyu-Misayama Rehabilitation Center Kakeyu Hospital, Nagano, Japan.
Motofumi Sumiya, Research Center for Child Mental Development, Hamamatsu University School of Medicine, Shizuoka, Japan.
Satoshi Tanaka, Laboratory of Psychology, Hamamatsu University School of Medicine, Shizuoka, Japan.
Author Contributions
Concept/idea/research design: K. Oyake, M. Sumiya, S. Tanaka
Writing: K. Oyake, K. Sue, M. Sumiya, S. Tanaka
Data collection: K. Oyake, K. Sue
Data analysis: K. Oyake, K. Sue, M. Sumiya, S. Tanaka
Project management: K. Oyake, S. Tanaka
Fund procurement: S. Tanaka
Providing participants: K. Oyake, K. Sue
Providing facilities / equipment: K. Oyake, S. Tanaka
Providing institutional liaisons: K. Oyake
Consultation (including review of manuscript before submitting): K. Oyake, K. Sue, M. Sumiya, S. Tanaka
Funding
This work was supported by a Japan Society for the Promotion of Science KAKENHI grant to S. Tanaka (JP20K21752 and JP20H04050).
Ethics Approval
The study was approved by the Institutional Review Board at Shinshu University (approval no. 4830) and at the Hamamatsu University School of Medicine (approval no. 20–206).
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
The unreviewed version of this manuscript was posted on the MedRxiv preprint server (https://www.medrxiv.org/content/10.1101/2022.04.20.22274114v1.full).
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data underlying this article will be shared on reasonable request to the corresponding author.