This study had a descriptive cross-sectional design. We used a convenience sampling web-based survey to obtain quantitative results from the participant perspective. The study protocol was approved by the appropriate ethics committee at the Hamamatsu University School of Medicine (approval number: 18-136). Informed consent was obtained from all participants.

Eligible participants were rehabilitation professionals including physicians, nurses, physical therapists, occupational therapists, speech-language-hearing therapists, or clinical psychologists currently working in rehabilitation. Participants were recruited with the cooperation of the 33rd conference of the Comprehensive Rehabilitation Ward Association and the 48th Annual Meeting of the Nagano Physical Therapy Association. To recruit participants, we set up a booth with laptops at each of the above-mentioned conferences. Professionals who were interested in participating in the study were able to access the survey website using the provided laptops. In addition, we distributed leaflets to professionals and displayed posters containing a brief description of the study and a hyperlink to the survey in front of the booth. Respondents were able to access the survey website using their own laptops, tablets, or smartphones. The first page of the survey informed participants about the total number of questions, the approximate time required to complete the survey, and the aim of the study. Participants were asked to report their professional category and years of experience working in stroke rehabilitation. Those who met the eligible criteria proceeded to the next page.

We consulted existing guidelines and followed a checklist when preparing the survey (15, 16). We chose to use a voluntarily accessed survey format developed using the Google Forms tool (Google LLC, Mountain View, CA, USA). Among the individuals who completed the survey, 50 were selected via a draw to receive an honorarium of 1,000 yen (~US $9.00).

The survey items regarding motivational strategies were developed based on the clinical experience of the authors, the findings of related literature (2–5, 7, 9, 11, 12, 17–20), and data obtained from semi-structured interviews with five professionals about motivational strategies for stroke rehabilitation (21). Stroke rehabilitation experts were asked to review the items for clarity, relevance, and topic coverage (22). We carried out a pilot test with a group of 10 rehabilitation professionals to determine whether the respondents understood the questions and instructions, and whether the meaning of the questions was the same for all respondents (16). The survey took an average of 15 min to complete. According to the qualitative feedback obtained from the semi-structured interviews with the 10 respondents, we made some minor grammatical changes to the survey. Consequently, we prepared a list of 22 motivational strategies (Table 1). In the first section of the survey, respondents were shown the list of motivational strategies and asked if they used each strategy in their clinical practice. Respondents were also asked to respond to an open-ended question at which point they were invited to propose additional motivational strategies that were not included in the list.

In the second section, for each motivational strategy that a respondent reported using, they were asked to state their aim when using that strategy. Specifically, they were asked to select from the following four purposes: (1) to increase the patient's interest in rehabilitation; (2) to make rehabilitation more worthwhile for the patient; (3) to help the patient gain confidence in performing a rehabilitation task; and (4) to increase patient satisfaction with the rehabilitation program. These purposes were based on the four sub-components of motivation proposed by the Attention, Relevance, Confidence, and Satisfaction (ARCS) model (23, 24). The ARCS model is a problem-solving approach that is used when designing motivational aspects of learning environments with the goal of stimulating and sustaining students' motivation to learn (23). In the third section, respondents were shown 11 items related to the patient health status, environmental factors, and personal factors (Table 2) (25). They were asked to select all of the items that they considered when deciding which motivational strategy to use. Finally, respondents were asked to report their gender, primary affiliation, and the phase of stroke recovery of the patients with which they most frequently worked.

We used the Cochran sample size formula to calculate the sample size. We set an alpha level a priori at 0.05, an acceptable error level of 5%, and a confidence interval of 95% (26). Consequently, a minimum of 384 participants were required. Assuming that the data from approximately 5% of the participants would be excluded from analysis, we aimed to recruit a total of 400 participants.

We used descriptive statistics to characterize the study sample and summarize the participant responses. The normality of distribution was tested using the Shapiro-Wilk test. We used Pearson's product-moment correlation coefficient or Spearman's rank correlation coefficient to test whether respondents with more experience used more motivational strategies. In addition, we used a stepwise multiple regression analysis to examine the relationship between the years of clinical experience and the number of motivational strategies used by each respondent, while controlling for potentially confounding variables. We included the respondents' gender, professional category, primary affiliation, and the patient phase of stroke recovery in the model as covariates. Dummy variables were used to incorporate categorical variables such as gender and professional category into the regression model. For the motivational strategies that were used by at least 75% of respondents (27), we conducted a hierarchical cluster analysis using Ward's method with a squared Euclidean distance to group them according to the purpose of use. Statistical analyses were performed using the Statistical Package for the Social Sciences software version 25.0 (International Business Machines Corp., NY, USA). Any p values < 0.05 were considered statistically significant.

This study was reported according to the recommended best practices and guidelines in the literature for the reporting of survey research (16, 22).

The percentages of respondents who used each of the presented motivational strategies are shown in Figure 2. The majority of the respondents (98.3%) selected “active listening” and “praise.” “Enjoyable communication,” “providing a suitable rehabilitation environment,” “goal setting,” “explaining the necessity of a practice,” and “respect for self-determination” were also selected by more than 90% of the respondents (95.3–91.7%). The majority of the respondents reported that they used “control of task difficulty,” “family member present,” “goal-oriented practice,” “providing medical information,” “application of patient preferences,” “practice related to patient's experience,” “providing opportunities to identify possible treatments,” and “specifying the amount of practice required” (89.2–76.0%). Thus, 15 out of the 22 presented strategies were selected by more than 75% of the respondents. Between 69.3 and 66.9% of the respondents reported that they used “allowing the patient to use a newly acquired skill,” “sharing the criteria for evaluation,” and “providing variations of the program.” Less than half of the respondents selected “practice with game properties,” “proposing conditions for exchange,” “using progress-confirming tools,” and “group rehabilitation” (49.2–34.5%). The results by professional category are shown in Supplemental Figure 1. The numbers of motivational strategies selected by at least 75% of the respondents who were nurses, physical therapists, and occupational therapists were 10, 15, and 18, respectively. The respondents proposed four additional motivational strategies (Supplemental Table 1). Respondents with more clinical experience tended to use a larger number of motivational strategies (rho = 0.208, 95% confidence interval = 0.105, 0.308, p < 0.001) (Figure 3). In addition, even when controlling for potentially confounding variables, the relationship between years of clinical experience and the number of motivational strategies used by each respondent remained significant (t = 2.027, p = 0.043).

For 11 of the 15 motivational strategies that were used by at least 75% of the respondents, the highest percentage of respondents reported that they used the strategies to make rehabilitation worthwhile for their patients (51.3–31.6%) (Figure 4A). For “control of task difficulty” and “praise,” the most common purpose was to help the patient gain confidence in performing a rehabilitation task (45.4 and 35.5%, respectively). The largest proportion of respondents who used “enjoyable communication” and “application of patient preferences” reported that they used these strategies to increase the patient's interest in rehabilitation (49.3 and 39.4%, respectively).

The hierarchical cluster analysis produced three motivational strategy clusters (Figure 4B). The first cluster included seven motivational strategies, such as “family member present” and “providing a suitable rehabilitation environment.” For six of these seven strategies, more than 30% of the respondents reported that they used the strategies to help the patients gain confidence in performing a rehabilitation task. The second cluster included six motivational strategies, such as “providing opportunities to identify possible treatments” and “explaining the necessity of a practice.” Most of the respondents used these to make rehabilitation worthwhile for their patient. The third cluster comprised two strategies that the largest percentage of respondents reported having used to increase the patient's interest in rehabilitation.

Each of the presented 11 items was selected by more than 75% of respondents as information that they considered when deciding which motivational strategy to use (Figure 5). Almost all of the respondents selected “patient's reaction to a presented motivational strategy” and “personality” (97.5%), whereas the lowest percentage of respondents selected “diagnosis” (75.4%). Furthermore, approximately half of the respondents selected all of the 11 presented items (49.1%). The results for each professional category are shown in Supplemental Figure 2. More than 75% of the respondents who were physicians and nurses selected all 11 of the presented items. More than 75% of the respondents who were physical therapists and occupational therapists selected all of the items except for "diagnosis,” whereas more than 75% of the respondents who were speech-language-hearing therapists selected all of the items excluding “social environment,” “comorbidities,” and “diagnosis.”

Active listening is one of the core communication skills used in counseling (11, 28). A systematic review reported that counseling has a positive effect on mood in stroke patients (11, 12). Praise can induce positive mood and increase motivation to perform a motor skill, resulting in improved performance (29–31). Moreover, daily feedback with praise has been reported to be effective in improving walking speed in stroke inpatients (9). Almost all of the respondents in our study reported that they actively listened to and praised their stroke patients to increase patient motivation regarding rehabilitation.

Our results suggest that the majority of the surveyed rehabilitation professionals recognized that the communication skills of the medical professional, rehabilitation environment, setting of goals, provision of information, and the presence of family members during practice could affect patient motivation regarding rehabilitation. These findings are consistent with those of Maclean et al. (3). Communication training programs for clinicians have been shown to increase patient satisfaction, levels of motivation for goal setting and action, and health-related quality of life (32). Sonoda et al. (33) found that providing a specific rehabilitation environment for stroke inpatients increased the amount of physical activity that they engaged in during activities of daily living. Furthermore, providing information about rehabilitation and insuring that a family member is present during rehabilitation may be effective in improving a patient's mood and encouraging them to become more active (12, 34).

Respect for self-determination, control of task difficulty, and provision of a goal-oriented practice were motivational strategies that were selected by more than 75% of the respondents. Self-determination contributes to the facilitation and maintenance of intrinsic motivation (35). The difficulty of a practice task is thought to have an important impact on the effectiveness of rehabilitation, as inappropriate levels of difficulty can lead the patient to become bored or frustrated (36). Indeed, gradual increases in task difficulty and goal-oriented practice have been recommended to facilitate functional motor recovery during stroke rehabilitation (1). Through clinical practice, rehabilitation professionals may have observed the effectiveness of these motivational strategies for increasing patient adherence to rehabilitation programs.

We found that the following four strategies were reportedly used by less than half of the respondents to motivate their patients: providing practice with game properties, proposing conditions for exchange, using progress-confirming tools, and providing group rehabilitation. The reasons why these particular motivational strategies were not used remain unclear. Environmental and time constraints, professional lack of confidence regarding the practice, and lack of perceived effectiveness may prevent rehabilitation professionals from using specific motivational strategies (37). In addition, some respondents may not have selected these strategies because they did not understand the accompanying motivational effects, even if they did use these strategies in clinical practice.

In clinical settings, rehabilitation professionals may be required to select strategies according to the cause of a patients' lack of motivation. Therefore, we examined the reasons for using each motivational strategy. For 11 of the 15 strategies used by the majority of respondents, the highest percentage of respondents reported that they used the strategy to make rehabilitation worthwhile for their patient. Lack of knowledge about the potential benefits of training may decrease patient adherence to rehabilitation (19). Therefore, professionals may emphasize patient comprehension regarding the benefits and significance of practices to motivate patients regarding rehabilitation.

Our hierarchical cluster analysis revealed three groups of motivational strategies. Strategies that center on the value of rehabilitation for patients, such as explaining the necessity of a practice and exercise, are expected to motivate patients with poor understanding regarding the benefits of rehabilitation. For patients with low confidence regarding their practice tasks, strategies focused on increasing patient confidence, such as control of task difficulty and praise, may be effective for increasing patient motivation. Moreover, engaging in enjoyable conversation and applying patient preferences to practice tasks are likely to increase patient interest and prevent patient boredom during rehabilitation. There were no strategies that were used by the majority of respondents to increase patient satisfaction with rehabilitation. However, more than a quarter of the respondents reported that they used goal setting, goal-oriented practice, and praise to increase patient satisfaction with rehabilitation. These strategies may be effective in motivating patients who are not satisfied with rehabilitation. Thus, our findings may help rehabilitation professionals to choose strategies from the list according to the cause of a patients' lack of motivation.

Maclean et al. (3) reported that compared with younger patients, older unmotivated stroke patients did not respond as well to encouragement. Thus, rehabilitation professionals may benefit from choosing motivational strategies according to the characteristics of each patient. Our results suggest that the majority of rehabilitation professionals choose motivational strategies based on comprehensive data regarding a patient's health condition, environmental factors, and personal factors. Patient personality type and responses to motivational strategies suggested by the professional seem to be regarded as especially essential information. Our findings may assist rehabilitation professionals in deciding which motivational strategy to use and contribute to the effective utilization of the motivational strategy list.

We also examined the participant responses by professional category (Supplemental Figure 2). We observed some differences in the responses among the different specializations. For example, while more than 75% of the physicians and nurses who participated answered that they utilized information regarding “diagnosis” when they decided which motivational strategies to use, this type of information was selected as useful by less than 75% of physical therapists, occupational therapists, and speech-language-hearing therapists. As physicians and nurses are responsible for medical management, they may be more likely to consider patient diagnosis as an important factor when choosing motivational strategies. These results may support our data indicating that different types of specialists use different strategies for motivation (Supplemental Figure 1). However, the sample of physicians and speech-language-hearing therapists in the present study was small. Thus, careful interpretation of the results by each professional category is necessary.

As mentioned above, our results showed that the different strategies were used for different purposes (Figure 4). For example, “control of task difficulty” and “praise” were most frequently used to help patients gain confidence in performing a rehabilitation task (45.4 and 35.5%, respectively), whereas the largest proportion of respondents who used “enjoyable communication” and “application of patient preferences” reported that they used these strategies to increase the patient's interest in rehabilitation (49.3 and 39.4%, respectively). However, our data suggested that many of these motivational strategies were used for one or more different purposes. For example, although the most common purpose for using “control of task difficulty” was to help patients gain confidence in performing a rehabilitation task (45.4%), the respondents also reported other purposes (10.4% to increase the patient's interest in rehabilitation; 31.2% to make rehabilitation worthwhile for the patient; 12.9% to increase patient satisfaction with rehabilitation). These different purposes for using motivational strategies might depend on the patient condition (e.g., age, comorbidities, and severity of stroke) and/or environmental factors. In the present study, we investigated the factors that are taken into consideration when rehabilitation professionals choose motivational strategies (Figure 5). However, we did not conduct concrete classifications of strategies according to the patient condition and environmental factors. Thus, future studies are needed to evaluate the motivational strategies that rehabilitation professionals use according to the patient condition and environmental factors.