Effect of the Rehabilitation Setting on Motivation and Clinical Outcomes Post Stroke - a Pilot Study

Abstract

Background: Previous research suggests that the rehabilitation setting can influence both motivation for rehabilitation and adherence to the rehabilitation programme. These two factors are considered important determinants of rehabilitation outcomes. Community rehabilitation is delivered at home or in a clinic, with clinic-based rehabilitation being provided either individually or in a group. Although research has shown that group exercise programmes can positively influence mobility outcomes following stroke, no community-based study has directly compared group and individual rehabilitation programmes using a similar content, to determine the effect on motivation and mobility outcomes.

Purpose: The purpose of this non-experimental pilot study was to undertake the feasibility work for a future randomised controlled trial (RCT) that would investigate whether the rehabilitation setting influences motivation for rehabilitation and clinical outcomes in patients with stroke. The motivation levels of two groups of participants undergoing community-based rehabilitation following stroke (group clinic-based and individual home-based rehabilitation) were evaluated to provide information about the required sample size for a future RCT. In addition, walking ability and adherence to the rehabilitation programme were compared in the two rehabilitation settings.

Methods: Sixteen participants, with a primary diagnosis of stroke, and who were referred for rehabilitation to the Community Rehabilitation Team in Wellington, were recruited. Participants completed rehabilitation in either a group clinic-based or individual home-based setting for up to eight weeks. Two motivation questionnaires, the Apathy Evaluation Scale (AES) and the Intrinsic Motivation Inventory (IMI), were administered and the Six Minute Walk Test (6MWT) was measured. Participants completed an exercise adherence diary to measure adherence to the prescribed home exercise programme (HEP), and the treating physiotherapist documented adherence to the rehabilitation sessions.

Results: A total sample size of ninety-six participants is recommended for a future RCT, to detect a minimum difference of five points on the AES between settings. No statistically significant difference in motivation levels between the two settings was found; however, the point estimates of the IMI were consistent with higher motivation levels in the group clinic-based setting. There was no statistically significant difference in 6MWT distance between the two groups, although the point estimates favoured home-based participants. There was no evidence of a difference in the degree of adherence to the rehabilitation sessions between the two settings. However, the group clinic-based participants had a statistically significant higher level of adherence to the prescribed HEP.

Conclusion: This pilot study showed a trend towards higher motivation levels in participants who received rehabilitation in a group clinic-based setting; however, this did not translate to improved clinical outcomes. Further research, using more robust methods and a larger sample size, is warranted to explore whether the rehabilitation setting affects motivation for rehabilitation and clinical outcomes following stroke. In addition, this study has highlighted the need for a review of the content of the group clinic-based rehabilitation programme.