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

You have motivation wrong. Write up 100% recovery protocols on this and survivors will do the millions of reps needed, no external motivation required. You don't understand one goddamn thing about stroke survivors, DO YOU? The problem is stroke researchers are not motivated to solve stroke. What the fuck is your solution to that failure?

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

Citation: Verrienti, G.; Raccagni, C.;
Lombardozzi, G.; De Bartolo, D.; Iosa,
M. Motivation as a Measurable
Outcome in Stroke Rehabilitation: A
Systematic Review of the Literature.
Int. J. Environ. Res. Public Health 2023,
20, 4187. https://doi.org/10.3390/
ijerph20054187
Academic Editor: Paul B. Tchounwou
Received: 18 December 2022
Revised: 22 February 2023
Accepted: 24 February 2023
Published: 26 February 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).International Journal of
Environmental Research
and Public Health
Review
Motivation as a Measurable Outcome in Stroke Rehabilitation:
A Systematic Review of the Literature
Giulio Verrienti 1,* , Cecilia Raccagni 2,3, Ginevra Lombardozzi 4, Daniela De Bartolo 5 and Marco Iosa 5,6
1 Department of Neurorehabilitation, Casa di Cura Villa Verde, 73100 Lecce, Italy
2 Department of Neurology, Provincial Hospital of Bolzano (SABES-ASDAA), Lehrkrankenhaus der Paracelsus
Medizinischen Privatuniversität, 39100 Bolzano, Italy
3 Department of Neurology, Innsbruck Medical University, 6030 Innsbruck, Austria
4 Von Siebenthal Neuropsychiatric Clinic and Hospital, 00045 Rome, Italy
5 Smart Lab, IRCCS Santa Lucia Foundation, 00179 Rome, Italy
6 Department of Psychology, Sapienza University of Rome, 00185 Rome, Italy
* Correspondence: gverrienti@villaverde.lecce.it; Tel.: +39-083224111

Abstract:  

Motivated behaviours are thought to lead to enhanced performances. In the neurore-
habilitation field, motivation has been demonstrated to be a link between cognition and motor
performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: “assessment” OR “scale” AND “motivation” AND “stroke” AND “rehabilitation”. In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.
Keywords: motivation; participation; apathy; stroke; neurorehabilitation; performance
1. Introduction
Although the concept of motivation may intuitively seem clear and simple, it poses
some hidden pitfalls. What do we mean when we say that a certain treatment “motivates”
patients? Is motivation a measurable parameter? Can we turn to motivation as it was
a clinical parameter? Despite intense research about this topic, these questions remain
probably open. In fact, motivation is a complex, multifaceted psychological construct,
resulting from the interplay of several factors. Up to now, indirect measurements, which
may provide a quantification of motivation, are available.
Motivation has been didactically defined as an orientation for which humans and other
animals activate and sustain behaviour toward a goal [ 1]. This definition can be applied
to several daily life scenarios. Motivation and its related aspects have been the subject of
numerous research studies and several competing theories, concerning the content of moti-
vated behaviours, have been regularly proposed. Among incentive theories, a distinction
between extrinsic and intrinsic motivation occurs frequently [2 ]. While intrinsic motivation
is related to the joy or to the interest by doing a certain activity, extrinsic motivation occurs
when the goal of an activity is an external reward, which is separated from the activity
itself. Research on motivation has been employed in multiple areas, including applications
in business [3 – 5], educational [ 6, 7], and wellness fields [8 ]. A specific branch of medical
Int. J. Environ. Res. Public Health 2023, 20, 4187. https://doi.org/10.3390/ijerph20054187 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2023, 20, 4187 2 of 25
research focused on determining factors which improve recovery from diseases. In this
context, motivation is of particular interest to neurologists, neuropsychologists, and experts
in neurorehabilitation since it is closely related to therapy outcome. Not surprisingly, highly
motivated patients are prone to reach a better recovery than low motivated patients [9]. In
the field of clinical research, a common measurement strategy of motivation represents an
unmet need.
This review aims at first to illustrate an overview of the most important general
motivation theories and, second, to place them with regard to the stroke rehabilitation
literature. Moreover, we investigated and compared motivation assessments, which have
been used in the last years in interventional studies on stroke patients in the rehabilitative
setting. Finally, at the light of the literature, we discussed how to assess motivation, which
might be helpful in further clinical research.
1.1. Theories on Motivation: An Overview
An academic, valid distinction between process and content theories about motivation
has been established: while process theories try to explain how and why motivation
influences behaviours, content theories attempt to define needs that motivate peoples’
actions. Among process theories, self-determination theory (SDT), social-cognitive theory
(SCT), and goal orientation theory (GOT) have been deeply investigated. All the above-
mentioned theories have been developed in different fields, in particular in the learning-
field. Some of these (especially the SDT, but also GOT and SCT) have been further extended
to re-learning processes, applying them in the neurorehabilitation setting. SDT represents a
macro theory of human motivation [3]. The concept of SD refers to the person’s faculty to
make choices, having a great impact on motivation. In fact, people feel more motivated
to act (“to make something”) if they observe an effect on the outcome of their own action.
According to Deci and Ryan [ 10 ], people tend to be driven in their actions by a need
to grow and gain fulfilment. In the cognitive evaluation theory, a sub-theory of SDT, a
subject becomes self-determined when needs for competence, connection, and autonomy
are satisfied. While autonomy refers to the human need to feel in control of behaviours,
competence means feeling confident with different task-related skills. Consequently, a
person who is confident to reach a goal is also more prone to take actions. Connection
is linked to the concept of relatedness. In this sense, a person needs to feel a sense of
belonging to the community. In the SDT, three main motivation domains were identified:
amotivation (lack of motivation), extrinsic motivation, and intrinsic motivation. While
in the intrinsic motivation an action is the result of an intrinsic will regulation, i.e., a
person makes something only for the enjoyment of the action, amotivation results in
inaction or action without real will. Inside extrinsic motivation many different levels of
regulation are related to different types of external value and to action’s consequences
(punishments/rewards).
In the SCT, motivation is the result of a cognitive process which is influenced by
personal, behavioural, and environmental factors. An essential role in this theory is played
by the subject’s faculty to change and manipulate the environment to reach personal goals.
This faculty is strongly influenced by the subject’s beliefs about their own capabilities.
The most important belief in the SCT is the (perceived) self-efficacy, defined by Albert
Bandura as “people’s judgment of their capabilities to organize and execute courses of
action required to attain designated types of performances. It is concerned ( . . . ) with
judgments of what one can do with whatever skills one possesses” [11].
The term goal orientation (GO) refers to the cognition of the achievement and its
implications on the behaviour responses [ 12 ]. GO influences the individual’s cognitive
or emotional tendency toward events, which in turn will trigger behavioural responses.
Within GO theories, orientation to achieve goals differs individually and it is related to a
subconscious subject’s predisposition. While some subjects show motivated behaviours
in task completing exclusively to align themselves with the community’s expectancy
(performance goal orientation), a mastery goals orientation leads to motivated behaviours.

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