Motivation is an important and at times challenging aspect of the rehabilitation process for many spinal cord injury (SCI) patients. In general, motivation is a complex, goal-oriented process that involves many factors. Although conceptually everyone understands motivation on a certain level, clearly defining, measuring or affecting motivation are more difficult propositions. A theoretical groundwork can help to lay a foundation for productive planning and undertaking of interventions. In attempting to define motivation and explain its processes, a number of concepts and definitions are useful. The American Psychological Association broadly defines motivation as…"the process of starting, directing, and maintaining physical and psychological activities; includes mechanisms involved in preferences for one activity over another and the vigor and persistence of responses".1

Box 1 | Motivation

Within a motivation process, there are three underlying variables that have been described and are considered integral 2:

  • Incentives (and incentive theory), hold that individual behaviour is influenced by beliefs that a given action will be profitable.
  • Drives (and drive theory) state that organisms have physiological needs (e.g. hunger) and behaviours are a response to satisfying these needs.
  • Reinforcement follows motivated behaviour that is promoted by drives and incentives and strengthens a given behaviour resulting from a stimulus.

While these variables help to describe some of the basic psychosocial elements that influence behaviours in the face of a stimulus, they all apply to the two distinct forms of motivation345:

Intrinsic motivation that lacks obvious external incentives and includes such phenomena as curiosity, play, hope for success and fear of failure – here the benefits are internal; and
Extrinsic motivation describes motivation influenced by factors or externalities outside an person that promote or determine behaviour based upon an end or goal such as financial gain or a high grade/mark (positive) or through coercion or avoidance of punishment (negative).

A further development that has been described is “a macro-theory of human motivation” known as self-determination theory. It is “concerned with the development and functioning of personality within social contexts... [focusing] on the degree to which human behaviours are volitional or self-determined”.6 While recognizing the importance of intrinsic and extrinsic motivation, it also includes three additional key factors: autonomy (i.e. not being controlled), promoting competence (e.g. through positive feedback) and a sense of relatedness.7

Motivation and Rehabilitation

While theories and variables help to more clearly define and describe motivation as a concept (Box 1), how to actually integrate motivation or its dependent factors into rehabilitation practice has been elusive. Furthermore, there has been some discussion as to what degree motivation has a role to play in rehabilitation given the challenges that are present in integrating it.78Siegert and Taylor (2003) argue compellingly that rehabilitation in general is goal-focused, and that motivation offers a solid theoretical foundation (with a basis in some of the aforementioned theories) that, with further research, may help to inform more effective rehabilitative approaches.8

However, although motivation is typically viewed as an important concept in the field of rehabilitation, it is also one that is difficult to measure objectively and prone to value judgment.8 For example, to what degree a person’s environment impacts motivation (vs. a person’s own personality/psychology) remains an open question. Through a better understanding of all factors that influence motivation rehabilitation professionals can better cope with the phenomenon of patient disengagement with rehabilitation.9

From anecdotal evidence, it is commonly thought that patients who are motivated are better able to undertake rehabilitation activities, leading to improved gains compared to patients who are less motivated.9 Given that goals and goal-setting are critical elements of rehabilitation management, patient motivation – despite the absence of concise definitions and metrics - is understood to be an important factor for achieving intervention targets and overall outcomes.9 Self-determination theory for example, has been thought to have potential applications in rehabilitation. It has been applied in educational contexts, highlighting the importance of providing explicit rationales in motivating relatively uninteresting activities.10 There may thus be yet future applications of such theories and approaches in the context of rehabilitation.

In trying to conceptualize motivation in the context of rehabilitation, Maclean and colleagues looked at fifty rehabilitation-focused studies undertaken over thirty years.9 They found three primary models of motivation in clinical contexts:

1. Individualistic: an internal and individual “personality trait” that is a “quality which is unaffected by social phenomena” and “cannot be explained by social factors”

With the individualistic perspective, motivation was often linked to therapeutic demands and an absence of motivation was considered a “defect”. From this standpoint, patients had even been labeled as having a specific health condition – Abnormal Illness behaviour (AIB) – “involving apathy, dependency, and the refusal to accept responsibility for recovery”. Among the studies, there was evidence that an individualistic perspective in rehabilitation could result in “moralizing”, where a motivated characteristic in a patient was viewed positively by health care providers.9

2. Social: a phenomena affected by social factors based on three central ideas -

  • common or divergent values between the patient and therapist
  • the abilities of the rehabilitation staff, including conflicting pressures from different health personnel, factors in the patient-therapist relationship and a provider’s communication ability
  • the nature of the patient’s network of social support, whereby low levels of both support and overprotection were found to be correlated with low motivation

3. Combined social and individualistic perspective: phenomena affected by social factors, personality and clinical characteristics that emphasizes the impact of both individual psychological traits and external social factors on motivation – a relevant perspective in rehabilitation contexts.

A number of studies have suggested, albeit in general terms, that the rehabilitation environment may have an effect on motivation.9 Researchers noted the importance of social factors on motivation, including such things as “goal-setting, home visits and excursions to places of entertainment”. Another example was found among those describing “Abnormal Illness behaviour” and its individualistic perspective, noting that determinants may include sharing or non-sharing of goals. Addressing the implications for rehabilitation, a number of practices may positively impact motivation (see Box 2).

Box 2 | Interventions that impact motivation

Factors that can positively impact motivation:

  • Clear and revisable goal-setting, including emphasizing longer-term goals beyond the clinical/rehabilitative setting
  • Helping the patient feel that their views on rehabilitation are “valid and welcome”;
  • Avoiding over-protection
  • Accepting the idiosyncrasies of a patient
  • Helping the patient see the therapist as “warm, approachable and competent”
  • Minimizing “mixed messages” among the health care team
  • Avoiding “actively clashing with the value system of the patient”
  • Understanding that the responsibility for a patient’s motivation lies not only with the patient.

Some of these elements (e.g. goal-setting) are inherently promoted within a structured rehabilitation management. Others need to be supported and integrated by individual health care providers.