Motivation as a Measurable Outcome in Stroke Rehabilitation: A Systematic Review of the Literature

[Assessment of upper limb rehabilitation exercise participation based on trajectory errors and surface electromyography signals]

At present, upper limb motor rehabilitation relies on specific rehabilitation aids, ignoring the initiative of upper limb motor of patients in the middle and late stages of rehabilitation. This paper proposes a fuzzy evaluation method for active participation based on trajectory error and surface electromyography (sEMG) for patients who gradually have the ability to generate active force. First, the level of motor participation was evaluated using trajectory error signals represented by computer vision. Then, the level of physiological participation was quantified based on muscle activation (MA) characterized by sEMG. Finally, the motor performance and physiological response parameters were input into the fuzzy inference system (FIS). This system was then used to construct the fuzzy decision tree (FDT), which ultimately outputs the active participation level. A controlled experiment of upper limb flexion and extension exercise in 16 healthy subjects demonstrated that the method presented in this paper was effective in quantifying difference in the active participation level of the upper limb in different force-generating states. The calculation results of this method and the active participation assessment method based on sEMG during the task cycle showed that the active participation evaluation values of both methods peaked in the initial cycle: (82.34 ± 9.3) % for this paper's method and (78.44 ± 7.31) % for the sEMG method. In the subsequent cycles, the values of both showed a dynamic change trend of rising first and then falling. Trend consistency verifies the effectiveness of the active participation assessment strategy in this paper, providing a new idea for quantifying the participation level of patients in middle and late stages of upper limb rehabilitation without special equipment mediation.

Motivational interviewing for improving functional and psychosocial outcomes among stroke survivors

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of motivational interviewing for functional and psychosocial outcomes in stroke survivors, compared to no intervention, waiting list, or attention controls.

Fun and games: a scoping review of enjoyment and intensity assessment in studies of game-based interventions for gait rehabilitation in neurological disorders

PURPOSE

Exergames are used to promote gait rehabilitation in patients with neurological disorders because they are believed to heighten patient enjoyment and training intensity. This scoping review evaluated whether and how studies support these claims.

METHODS

A search for studies published up until October 2023 involving virtual reality or exergames for patients with neurological disorders (stroke, Parkinson's disease, multiple sclerosis, spinal cord injury) was conducted on PubMed and Scopus, with additional articles identified through backward and forward citation searching. Studies collecting gait measurements, with at least five participants and a control group were included. Data extracted were rationale, and whether participants' enjoyment of the intervention and training intensity were assessed.

RESULTS

1060 records were identified with 58 included in this review. There were 34 articles on stroke, 11 on multiple sclerosis, and 13 on Parkinson's disease. Participant enjoyment and greater training intensity were important rationales but were only evaluated in 12 and seven of the included studies, respectively.

CONCLUSION

Results highlight that participant enjoyment and heightened training intensity are commonly cited rationales for using exergames in gait rehabilitation, but these effects are assumed and not routinely measured or analysed. Greater consistency is needed in the design and execution of exergaming studies for neurological disorders.

Feasibility of Smartphone-Based Exercise Training Integrated with Functional Electrical Stimulation After Stroke (SETS): A Preliminary Study

One emerging method in home stroke rehabilitation is digital technology. However, existing approaches typically target one domain (e.g., upper limb). Moreover, existing interventions do not cater to older adults with stroke (OAwS), especially those with high motor impairment, who require adjunct therapeutic agents to independently perform challenging exercises. We examined the feasibility of Smartphone-based Exercise Training after Stroke (SETS) with Functional Electrical Stimulation (FES). A total of 12 participants (67 ± 5 years) with stroke (onset > 6 months) exhibiting moderate-to-high motor impairment (Chedoke McMaster Leg ≤ 4/7) underwent 6 weeks of multicomponent (gait, functional strength, dynamic balance) training integrated with FES to paretic lower limb muscles. Primary measures included safety and adherence. Secondary measures included motivation, acceptability and attitude, usability, and clinical measures of gait and balance function like the 10-Meter Walk Test and Mini-BESTest. Participants reported no adverse events and moderate-to-high adherence (84.17 ± 11.24%) and improvement (up to 40%) in motivation, acceptability, and attitude and system usability. Participants also showed pre-post improvements in all measures of gait and balance function (p < 0.05). Integrating SETS and FES is feasible and yields short-term gains in gait and balance function among OAwS. Future studies could validate our findings by examining its efficacy with control groups to identify the differential effects of SETS and FES.

Mim-pong: a serious game for assessment and treatment of the lower limb in hemiparetic stroke patients

Introduction

The motor impairment evidenced post-stroke results in limitations to performing activities of daily living (ADL), especially when it involves locomotion. The Serious Games (SG) are an interesting therapeutic option, as they allow the performance of exercises according to stroke treatment guidelines. However, there is little research exploring the evaluation potential of SG. This study aimed to evaluate the possible metric properties of the mim-pong SG in addition to the therapeutic effects.

Methods

Twenty-four hemiparetic stroke patients were divided into two non-randomized groups: the experimental group (EG) (n = 16) and the control group (CG) (n = 8). Participants were evaluated in terms of motor impairment (lower limb), muscle strength (MS), motor control, and functional mobility.

Results

The significant correlations observed between the score generated by the SG and clinical variables in both groups are highlighted, especially with MS (rho = 0.62-0.66; p = 0.000, and rho = 0.67-0.71; p = 0.002-0.005, for the experimental and CGs, respectively) and motor function of the lower limb for the EG (rho = 0.41, p = 0.018). In addition, the results indicated improvements in all variables in the EG, with superiority over the CG.

Conclusions

This study showed that the mim-pong serious game could be considered a potential resource for the assessment and treatment of hemiparetic stroke patients.

Appraising motivation as a predictor of independence in individual activities of daily living in patients with subacute stroke: a retrospective study

OBJECTIVES

This study aimed to evaluate the impact of motivation on independence in activities of daily living, such as eating, getting up, and rehabilitation, in subacute stroke patients.

MATERIALS AND METHODS

We retrospectively assessed the data of 191 first-stroke patients in a rehabilitation hospital ward. Motivation was examined using the following five elements of the Vitality Index: waking pattern, communication, feeding, on and off toilet, and rehabilitation and other activities. As an outcome measure, independence in activities of daily living, such as eating and dressing, was assessed using the Barthel Index. Logistic regression analysis was performed using the independence of each activities of daily living, as determined by the Barthel Index at discharge, as a dependent variable and each of the Vitality Index item scores as the independent variable.

RESULTS

Motivation to get up item of the Vitality Index was significantly associated with independence in grooming and dressing, whereas motivation to communicate item was significantly associated with independence in transferring (p < 0.05). Furthermore, motivation to eat item was significantly associated with independence in feeding, grooming, dressing, and transferring, whereas motivation to engage in rehabilitation and activities was significantly associated with independence in dressing, transferring, and toileting (p < 0.05).

CONCLUSIONS

Our results suggest that the motivation to eat, get up, communicate, and participate in rehabilitation and activities is associated with independence in different activities of daily living. The present study provides useful insights into the significance and interpretation of assessing motivation on independence in activities of daily living.

Patient motivation: A concept analysis

Background

Patient motivation is crucial in maintaining health-improving activities and helping patients recover from illnesses. Despite extensive research on patient motivation, this concept has not been clearly defined and remains ambiguous. The latest analysis of patient motivation was over two decades ago, thus necessitating the need to reexamine it in more updated literature.

Objective

This study aims to explore the concept of patient motivation.

Methods

The eight-step approach of Walker and Avant was used: concept selection, determining analysis aim, identifying concept use, defining attributes, model case identification, borderline and contrary case identification, antecedents and consequences identification, and empirical referent identification. Five databases, CINAHL, Cochrane, Medline, PubMed, ProQuest, and ScienceDirect, were searched for published works between 2014 and 2024 using the keywords "patient" and "motivation."

Results

The identified attributes of patient motivation are a psychological drive, a desire to adopt healthy behaviors, and goal-directed action. Antecedents of patient motivation are self-efficacy, provider-patient communication, and social support. Patient motivation leads to consequences, including healthier lifestyles and greater adherence and compliance.

Conclusion

The present concept analysis draws upon current literature to suggest the antecedents, attributes, and consequences of patient motivation. Nurses can promote healthier lifestyles and greater adherence and compliance among patients by employing techniques to raise self-efficacy and provide social support while enhancing patient-centered interactions.

Music therapy with adults in the subacute phase after stroke: A study protocol

Stroke is a highly disabling condition, for which music therapy is regularly used in rehabilitation. One possible mechanism for the effects of music therapy is the motivational aspect of music, for example regarding treatment adherence based on improved mood. In this study, changes in motivation related to Neurologic Music Therapy (NMT) techniques during rehabilitation in the subacute phase after stroke will be investigated. Using a randomised within-subjects cross-over design, the effects of two NMT techniques and related motivational indices will be investigated. Data will be collected at three timepoints: baseline (TP1), after being randomised into groups and receiving NMT or standard care (TP2), and then at a third time point after the cross-over and having received both conditions (TP3). This design allows to counteract order effects, time effects due to spontaneous and/or nonlinear recovery, as well as single-subject comparisons in a relatively heterogeneous sample. Twenty adult participants who have experienced a supratentorial ischaemic or haemorrhagic stroke and are experiencing upper-limb impairments and/or cognitive deficits will be included. Behavioural measures of motor function, cognition, and quality of life will be collected, along with self-reported indices of overall motivation. The study outcomes will have implications for the understanding of the underlying mechanisms of music therapy in stroke recovery, more specifically regarding the relevance of motivational states in neurorehabilitation.

Efficacy of videogames and exergames in pediatric neurorehabilitation: a systematic review

INTRODUCTION

In recent years, the rehabilitation of children with neurological disorders has taken into account the possibility of using videogaming consoles and virtual reality systems to make children's therapy more enjoyable, motivating, participated and effective. This study aims at conducting a systematic review about the use and the efficacy of digital games in pediatric neurorehabilitation.

EVIDENCE ACQUISITION

In accordance with the PRISMA approach, a rather wide-ranging search was conducted on PubMed, Scopus, and Web of Science databases by using different combinations of keywords based on MeSH terms.

EVIDENCE SYNTHESIS

Fifty-five papers have been included into this review, namely, 38 original studies and 17 reviews. The total number of children and adolescents is 573, with 58% of them being affected by cerebral palsy. Despite a wide variability in the adopted protocols, devices, assessment tools, and a more frequent focus on motor aspects than on cognitive ones, the results of the majority of the analyzed studies support the safety (i.e., absence of severe adverse effects) and efficacy of the videogame-based therapy.

CONCLUSIONS

Videogames, when administered by means of commercial consoles or ad-hoc digital systems, seem to be a valid support for physical therapy. Further researchers are needed to deeply investigate the role of this approach in cognitive therapy and cognitive outcomes.

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.

Motivational strategies used by health care professionals in stroke survivors in rehabilitation: a scoping review of experimental studies

Introduction

Cognitive and motor impairments are common among stroke survivors. Physical therapy is often used to improve the functional capacity of stroke survivors. However, limited adherence to rehabilitation programs is a challenge. Motivation plays a crucial role in the success of rehabilitation programs as it influences individual adherence to treatment and overall health outcomes. This review aims to identify current trends in motivational strategies used by healthcare professionals for stroke survivor rehabilitation.

Methods

Following the framework developed by Arksey and O'Malley, a scoping review was conducted. We performed a literature search using MEDLINE, CINAHL, the Cochrane Central Register of Controlled Trials, Nursing & Allied Health, and MedicLatina databases.

Results

A total of 906 papers were identified. After selecting and analyzing the articles, 17 papers were included in this review. Health professionals use various strategies to motivate stroke survivors. These approaches include establishing a therapeutic alliance, improving patients' health literacy, defining realistic goals, fostering problem-solving skills, personalizing the rehabilitation program, showcasing success stories, utilizing persuasive techniques, offering encouragement and compliments, providing emotional support, and effectively managing symptoms.

Conclusion

The knowledge gathered in this review can guide healthcare professionals in helping patients overcome barriers to rehabilitation, improve their motivation, and ultimately enhance their recovery outcomes.

The effect of reward on motor learning: different stage, different effect

Motor learning is a prominent and extensively studied subject in rehabilitation following various types of neurological disorders. Motor repair and rehabilitation often extend over months and years post-injury with a slow pace of recovery, particularly affecting the fine movements of the distal extremities. This extended period can diminish the motivation and persistence of patients, a facet that has historically been overlooked in motor learning until recent years. Reward, including monetary compensation, social praise, video gaming, music, and virtual reality, is currently garnering heightened attention for its potential to enhance motor motivation and improve function. Numerous studies have examined the effects and attempted to explore potential mechanisms in various motor paradigms, yet they have yielded inconsistent or even contradictory results and conclusions. A comprehensive review is necessary to summarize studies on the effects of rewards on motor learning and to deduce a central pattern from these existing studies. Therefore, in this review, we initially outline a framework of motor learning considering two major types, two major components, and three stages. Subsequently, we summarize the effects of rewards on different stages of motor learning within the mentioned framework and analyze the underlying mechanisms at the level of behavior or neural circuit. Reward accelerates learning speed and enhances the extent of learning during the acquisition and consolidation stages, possibly by regulating the balance between the direct and indirect pathways (activating more D1-MSN than D2-MSN) of the ventral striatum and by increasing motor dynamics and kinematics. However, the effect varies depending on several experimental conditions. During the retention stage, there is a consensus that reward enhances both short-term and long-term memory retention in both types of motor learning, attributed to the LTP learning mechanism mediated by the VTA-M1 dopaminergic projection. Reward is a promising enhancer to bolster waning confidence and motivation, thereby increasing the efficiency of motor learning and rehabilitation. Further exploration of the circuit and functional connections between reward and the motor loop may provide a novel target for neural modulation to promote motor behavior.

Current Trends in Gait Rehabilitation for Stroke Survivors: A Scoping Review of Randomized Controlled Trials

BACKGROUND

Stroke stands as a significant global health concern, constituting a leading cause of disability worldwide. Rehabilitation interventions are crucial in aiding the recovery of stroke patients, contributing to an overall enhancement in their quality of life. This scoping review seeks to identify current trends in gait rehabilitation for stroke survivors.

METHODS

The review followed the methodological framework suggested by Arksey and O'Malley. Electronic databases, such as CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection, were systematically searched in November 2023. Inclusion criteria comprised papers published in either English or Portuguese from 2013 to 2023.

RESULTS

From the initial search, a total of 837 papers were identified; twenty-one papers were incorporated into this review. Thirteen distinct categories of gait rehabilitation interventions were identified, encompassing diverse approaches. These categories comprise conventional rehabilitation exercises, traditional gait training with integrated technology, and gait training supported by modern technologies.

CONCLUSIONS

Although traditional rehabilitation exercises have historically proven effective in aiding stroke survivors, a recent trend has emerged, emphasizing the development and integration of innovative therapeutic approaches that harness modern technologies.

The presence of anhedonia in individuals with subacute and chronic stroke: an exploratory cohort study

Background

Anhedonia refers to the diminished capacity to experience pleasure. It has been described both as a symptom of depression and an enduring behavioral trait that contributes its development. Specifically, in stroke patients, anhedonia has been closely linked to depression, resulting in reduced sensitivity to everyday pleasures and intrinsic motivation to engage in rehabilitation programs and maintain a healthy active lifestyle. This condition may hinder patients' recovery, diminishing their autonomy, functioning, and quality of life.

Objective

We aimed to explore the prevalence and level of anhedonia and those variables that might be associated in patients with both ischemic and hemorrhagic stroke at subacute and chronic phases of the disease.

Methods

We conducted an exploratory cohort study with a sample of 125 patients with subacute and chronic stroke presenting upper-limb motor deficits. We measured participants' level of anhedonia with four items from the Beck Depression Inventory-II that describe the symptoms of this condition: loss of pleasure, loss of interest, loss of energy, and loss of interest in sex. We also collected demographic and clinical information and evaluated motor and cognitive functions as well as levels of depression, apathy, and various mood states. The results were compared to a sample of 71 healthy participants of similar age, sex, and level of education.

Results

Stroke patients demonstrated a significantly higher prevalence (18.5-19.7%) and level of anhedonia compared to the healthy controls (4.3%), regardless of stroke phase, level of motor impairment, and other clinical variables. Furthermore, post-stroke anhedonia was associated with lower levels of motivation and higher levels of negative mood states such as fatigue and anger in the long term. Importantly, anhedonia level was superior in stroke patients than in healthy controls while controlling for confounding effects of related emotional conditions.

Conclusion

This study provides novel evidence on the prevalence, level and factors related to anhedonia post-stroke. We emphasize the importance of assessing and treating anhedonia in this population, as well as conducting large-scale cohort and longitudinal studies to test its influence on long-term functional and emotional recovery.

Improving Outcomes in People with Spinal Cord Injury: Encouraging Results from a Multidisciplinary Advanced Rehabilitation Pathway

Spinal cord injury (SCI) consists of damage to any segment of the spinal cord extending to potential harm to nerves in the cauda equina. Rehabilitative efforts for SCI can involve conventional physiotherapy, innovative technologies, as well as cognitive treatment and psychological support. The aim of this study is to evaluate the feasibility of a dedicated, multidisciplinary, and integrated intervention path for SCI, encompassing both conventional and technological interventions, while observing their impact on cognitive, motor, and behavioral outcomes and the overall quality of life for individuals with SCI. Forty-two patients with SCI were included in the analysis utilizing electronic recovery system data. The treatment regimen included multidisciplinary rehabilitation approaches, such as traditional physiotherapy sessions, speech therapy, psychological support, robotic devices, advanced cognitive rehabilitation, and other interventions. Pre-post comparisons showed a significant improvement in lower limb function (Fugl Meyer Assessment-FMA < 0.001), global cognitive functioning (Montreal Cognitive Assessment-MoCA p < 0.001), and perceived quality of life at both a physical and mental level (Short Form-12-SF-12 p < 0.001). Furthermore, we found a significant reduction in depressive state (Beck Depression Inventory-BDI p < 0.001). In addition, we assessed patient satisfaction using the Short Form of the Patient Satisfaction Questionnaire (PSQ), offering insights into the subjective evaluation of the intervention. In conclusion, this retrospective study provides positive results in terms of improvements in motor function, cognitive functions, and quality of life, highlighting the importance of exploring multidisciplinary approaches.

Exploring the efficacy of virtual reality-based rehabilitation in stroke: a narrative review of current evidence

BACKGROUND

Stroke rehabilitation presents a complex challenge, necessitating innovative approaches to optimise functional recovery. Virtual Reality-Based Rehabilitation (VRBR) has emerged as a promising intervention that capitalises on immersive technology to engage stroke survivors in their recovery journey. This review aims to examine the efficacy of VRBR in stroke rehabilitation, focusing on its advantages and challenges.

METHODS

A comprehensive search of relevant literature was conducted to gather evidence on the efficacy of VRBR in stroke survivors. Studies that investigated the impact of VRBR on patient engagement, functional recovery, and overall rehabilitation outcomes were included. The review also assessed the ability of VRBR to simulate real-life scenarios and facilitate essential daily activities for stroke survivors.

RESULTS

The review highlights that VRBR offers a unique immersive experience that enhances patient engagement and motivation during rehabilitation. The immersive nature of VRBR fosters a sense of presence, which can positively impact treatment adherence and outcomes. Moreover, VRBR's capacity to replicate real-world scenarios provides stroke survivors with opportunities to practice vital daily activities, promoting functional independence. In contrast, conventional rehabilitation methods lack the same level of engagement and real-world simulation.

CONCLUSION

VRBR holds promise as an efficacious intervention in stroke rehabilitation. Its immersive nature enhances patient engagement and motivation, potentially leading to better treatment adherence and outcomes. The ability of VRBR to simulate real-life scenarios offers a unique platform. However, challenges such as cost, equipment, patient suitability, data privacy, and acceptance must be addressed for successful integration into stroke rehabilitation practice.