Asian J Gerontol Geriatr 2012; 7: 807

Validation of the Stroke Rehabilitation ORIGINAL ARTICLE

Motivation Scale: a pilot study
GN White MSc,1 DJ Cordato PhD, MBBS, FRACP,2 F O'Rourke MBBS, FRACP,
MRCP,1 RL Mendis MBBS,3 D Ghia MBBS,2 DKY Chan MD, MBBS, MHA,
FRACP, AFCHSE1,3

ABSTRACT 1
Department of Aged Care and
Rehabilitation, Bankstown Hospital,
Objective. To develop and validate a Stroke Rehabilitation Motivation NSW, Australia
Scale (SRMS). 2
Department of Neurology, Liverpool
Hospital, NSW, Australia
Methods. In stage 1, the 28-item SRMS was adapted from the Sports 3
Faculty of Medicine, University of New
Motivation Scale and tested for internal and inter-rater reliability in 18 South Wales, NSW, Australia
patients. The 7 most reliable items were selected for the 7-item SRMS.
In stage 2, the 7-item SRMS was tested in 13 additional patients.
Results. In a group of 19 men and 12 women, the mean total score of
the 7-item SRMS was 24.1 (standard deviation, 4.6; range, 7-35). 25
patients had normal-to-high motivation (score of 21) and 6 had low
motivation (score of <20). Good internal consistency (Cronbachs alpha
of >0.5) and inter-rater reliability (as measured by intra-class correlation
coefficient of >0.5) was demonstrated in the 28-item group (n=18).
There was less consistency in the 7-item sample; the Cronbachs alpha
for intrinsic items was 0.61, but was only 0.27 for extrinsic items.
Conclusion. The 28-item SMRS showed good inter-rater reliability
and internal consistency. The reliability of the 28-item SRMS suggests
that adaptation of the SRMS from the Sports Motivation Scale was
successful. Correspondence to: Prof Daniel KY Chan,
Department of Aged Care and Rehabilitation,
Bankstown Hospital, NSW, Australia.
Key words: Motivation; Questionnaires; Rehabilitation; Stroke E-mail: daniel.chan@sswahs.nsw.gov.au

INTRODUCTION rehabilitation outcomes.4-12 A survey of rehabilitation

Stroke can have a devastating effect on patients
and their families in terms of the burden associated
with disability. Pharmacotherapy and psychosocial
intervention are recommended for treatment of
the effects of stroke on mood.1,2 According to the
European Stroke Initiative guidelines,1 rehabilitation
should start as soon as the patient is clinically stable,
and continue as long as functional improvement
is observed. Nonetheless, psychological and
social issues are not addressed. Early recognition
of psychological problems may prevent decline
or entrenchment into a cycle of functional
deterioration.3
Motivation plays an important role
professionals in the UK found that patients are
usually not involved in goal-setting meetings, and
only 60% are informed of the rehabilitation goals.8
Nonetheless, excess rehabilitation may tire patients
inadvertently and lead to decreased motivation.6
There are no validated instruments to measure
motivation of a stroke patient, although there is a
concept of an 'unmotivated patient'.10 A qualitative
study of motivation in stroke patients undergoing
rehabilitation identified high- and low-motivation
patients and explored the attitudes and beliefs of
those patients.4 High-motivation patients felt that
education from professionals changed their thinking
from a magical solution to the necessity of an active
role in rehabilitation. There are internal and external
in factors that may affect motivation.

80 Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012


This study aimed to design and validate a
stroke-specific rehabilitation motivation scale, and
determine whether motivation is conceptually
distinct from stress, anxiety, or depression.
METHODS
Ethics approval was granted by the Human Ethics
and Research Committee of Sydney South Western
Area Health Service (Western Zone) and the Ethics
Committee of the University of New South Wales,
Sydney, Australia.
To devise a tool for the assessment of motivation
in a cohort of acute post-stroke in-patients deemed
eligible for rehabilitation, the 28-item Stroke
Rehabilitation Motivation Scale (SRMS) [Appendix
1] was adapted from the Sports Motivation Scale
(SMS),13,14 because (1) the SMS measures internal
and external influences on motivation; (2) it has
been successfully adapted from, and to, other
different fields, e.g. the Academic Motivation
Scale,15 Client Motivation for Therapy Scale,16
Situational Motivation Scale,17 and Regulation of
Eating Behaviours Scale18; and (3) it is based on an
accepted theory of motivation (self-determination
theory14).
According to self-determination theory,
motivation can be divided into intrinsic and extrinsic
domains. For the former, behaviours are performed
for personal satisfaction, interest, and enjoyment.
For the latter, behaviours are influenced by external
factors (such as social expectation) and carried out to
attain contingent outcomes.13,14,19
The SMS and SRMS consist of 7 subscales:
(1) Extrinsic Motivation Introjected (EMIn)
motivation from external factors that result in
internal pressure such as guilt or embarrassment,
(2) Extrinsic Motivation Regulation (EMR)
motivation from external rewards such as praise
by doctors or family, (3) Extrinsic Motivation
Identification (EMId)motivation from individual
personal growth, (4) Amotivation (AM), (5) Intrinsic
Motivation Knowledge (IMK)motivation from
learning and development, (6) Intrinsic Motivation
Stimulation (IMS)motivation from pleasure or
personal enjoyment, and (7) Intrinsic Motivation
Accomplishment (IMA). Appendix 2 shows the
corresponding item numbers between the 2 scales.
Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012
Validation of the Stroke Rehabilitation Motivation Scale
Participants were chosen from the stroke units
of 2 large metropolitan hospitals in New South
Wales, Australia: Bankstown-Lidcombe Hospital
and Liverpool Hospital. The former was reported
to have good patient outcomes and comparatively
short length of hospital stay.20 Acute stroke patients
undergoing rehabilitation were included; those with
aphasia, transient ischaemic attack or insufficient
deficits for physiotherapy, and inability to speak
English were excluded. In first 24 to 48 hours post-
stroke, patients were administered the following
tests: National Institutes of Health Stroke Scale,21
Mini-Mental State Examination,22 and modified
Rankin Scale.23 Patients were then administered
the SRMS (by one researcher) after beginning
rehabilitation, and then the SRMS (by another
researcher), Hospital Anxiety and Depression
Scale,24 and Perceived Stress Scale25 2-3 days after
the first SRMS.
The SRMS questionnaire was administered face-
to-face, and researchers filled out each patients
responses in order not to exclude hemiparetic patients.
In stage 1, the questionnaire was administered twice
within 3 days by 2 different researchers blinded
to each others rating scores. The 28-item SRMS
comprised 7 sets of questions, each for 4 subscales
of motivation. Inter-rater reliability was tested using
the intra-class correlation coefficient (ICC), scale
reliability, and validity in 18 stroke patients from
Bankstown-Lidcombe Hospital from May 2007 to
October 2007. In stage 2, an additional 13 patients
were recruited from Liverpool Hospital between
May 2008 and June 2008 (n=5) and Bankstown-
Lidcombe Hospital between April 2008 and June
2009 (n=8). The patients were tested for scale
reliability, and for correlations between motivation
score, rehabilitation outcomes, and measures of
mood (anxiety, depression, and stress). The 7-item
SRMS was devised from the 28-item SRMS by
consensus. All 7 subscales were important clinically
and relevant to stroke rehabilitation. One item from
each subscale with the best reliability (highest item-
to-total correlation) was chosen (Table 1). The total
score of the 7-item SRMS ranged from 7 to 35.
Higher scores indicated higher motivation. Scores of
21 were considered normal to high motivation.
Inter-rater reliability was tested using intra-
class correlation (consistency model). Internal
consistency was investigated using Cronbachs
81
White et al

Table 1
Reliability of 28-item Stroke Rehabilitation Motivation Scale (SRMS)

SRMS item (question no.) Item-to-total correlation Cronbach's alpha Intra-class correlation coefficient
1st test 2nd test
Extrinsic Motivation Introjected 0.173 0.53
1 0.420 0.503
8 0.409 0.610
15 0.242 0.616
22 0.697 0.624
Amotivation 0.554 0.577
2 0.662 0.628
9 0.377 0.696
16 0.329 0.464
23 (reverse) 0.633 0.825
Intrinsic Motivation Knowledge 0.723 0.858
3 0.602 0.875
10 0.684 0.858
17 0.508 0.483
24 0.781 0.857
Extrinsic Motivation Regulation 0.738 0.502
4 0.678 0.475
11 0.634 0.840
18 0.795 0.910
25 0.765 0.932
Extrinsic Motivation Identification 0.548 0.606
5 (reverse) 0.560 0.381
12 (reverse) 0.843 0.827
19 - -0.211
26 0.390 -0.085
Intrinsic Motivation Stimulation 0.806 0.792
6 0.623 0.633
13 0.764 0.898
20 0.778 0.779
27 0.685 0.845
Intrinsic Motivation Accomplishment 0.775 0.793
7 0.803 0.728
14 0.844 0.889
21 0.731 0.523
28 0.718 0.660

alpha, item-to-total correlation, and item-to-item
correlation. The Cronbachs alpha for each sub-scale
indicated the overall reliability of that sub-scale as a
whole, whereas ICC measured inter-rater reliability
between 2 researchers. An ICC of 0.8 indicated very
high reliability between raters, and 0.5 indicated fair
reliability.26 Item-to-total correlation indicated the
correlation between each item and its sub-scale,
in both raters. Scores >0.5 were acceptable, and
scores >0.8 indicated excellent reliability. Length of
hospital stay was adjusted by dividing the change
in rehabilitation scores from admission to discharge

82 Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012


(change in sit-to-stand height in cm, distance
walked in 6 minutes, and 10-metre walking speed in
m/second) by the length of hospital stay to give a per
day scoring.
RESULTS
Of the 34 participants enrolled in the study, 3
were lost to follow-up and excluded from the
analysis. The remaining 19 men and 12 women
had sustained an ischaemic stroke (n=28) or a
haemorrhagic stroke (n=3). During the study period,
269 patients were admitted to the stroke units of
the 2 hospitals but not included in the study. 50 of
them were not assessed or refused to participate
and 219 patients had a transient ischaemic attack
or a minor stroke with insufficient impairment to
require physiotherapy (n=83), inability to speak
English (n=59), death due to stroke or palliative care
treatment and/or comorbidities (n=29), dementia or
cognitive impairment (n=28), or aphasia/dysphasia
(n=20). The length of hospital stay was significantly
longer for the participants than for those who did
Patient demographics
Parameter Excluded patients (n=269)
MeanSD length of hospital stay (days)
MeanSD age (years)
No. (%) of patients
Males
Females
No. (%) of patients
Bankstown-Lidcombe Hospital
Liverpool Hospital
Table 3
Internal reliability of extrinsic and intrinsic items from the 7-item Stroke Motivation Rehabilitation Scale
Reliability
Extrinsic items (n=3)
Extrinsic Motivation Regulation (question 1)
Extrinsic Motivation Identification (question 4)
Extrinsic Motivation Introjected (question 5)
Intrinsic items (n=3)
Intrinsic Motivation Stimulation (question 2)
Intrinsic Motivation Accomplishment (question 3)
Intrinsic Motivation Knowledge (question 7)
Validation of the Stroke Rehabilitation Motivation Scale
not participate (20.9 vs. 31.7 days; p<0.01) [Table 2].
With the exception of EMIn (Cronbachs
alpha=0.173), all sub-scales demonstrated adequate
reliability. For ICC, all sub-scales scored >0.5
indicating fair inter-rater reliability. A lower limit of
0.5 for item-to-total correlation was applied.27 16
questions had item-to-total correlation of >0.5 in
both administrations. The items with highest scores
within each sub-scale were retained to form a 7-item
SMRS (Table 1). The scores for question 1 (EMId)
and question 6 (AM) were reversed for the purpose
of a final 7-item SRMS score (range, 7-35).
Internal reliability for the 3 extrinsic items and 3
intrinsic items of the 7-item SRMS is shown in Table
3. Reliability analysis was not performed for question
6 (amotivation), as it represented a single item. For
the extrinsic items, Cronbachs alpha and individual
item-to-total correlations were <0.5 (EMR=0.263,
EMId=0.085, EMIn=0.103), as the items were
selected from different extrinsic subscales and were
not necessarily a measure of the same factor. For
Table 2
Included patients (n=31) p Value
20.920.9 31.720.2 0.005
74.912.5 71.714.7 0.47
0.826
128 (48) 19 (61)
141 (52) 12 (39)
0.742
224 (83) 26 (84)
45 (17) 5 (16)
Cronbach's alpha Item-to-total correlation
0.27 -
- 0.263
- 0.085
- 0.103
0.61 -
- 0.309
- 0.402
- 0.592
Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012 83
White et al
Correlations between rehabilitation outcomes, 7-item Stroke Rehabilitation Motivation Scale score, and depression, anxiety,
Parameter Sit-to-stand rate Walking distance
(cm/day) [n=31] rate (m/day) [n=31]
Median (IQR) 0.2 (0.1-0.4)
Motivation score correlation
Pearson correlation -0.13
Significance (2-tailed) 0.49
intrinsic items, Cronbachs alpha (0.61) and the
individual item-to-total correlations (IMS=0.309,
IMA=0.402, IMK=0.592) were higher.
The mean total score of the 7-item SRMS was 24.1
(standard deviation, 4.6). 25 patients had a normal-
to-high motivation score (21-35), and 6 patients
had a low motivation score (7-20). There were no
correlations between measures of mood (depression,
anxiety, and stress), rehabilitation outcomes (sit-
to-stand height and walking distance, adjusted for
length of hospital stay), and the 7-item SRMS score
(Table 4). Stress showed a variance, with a median
of 7 (interquartile range, 3-15.5). This suggests some
patients did not find their hospital stay stressful.
There were no significant negative correlations
between 7-item SRMS motivation scores, depression
(r=-0.24, p=0.21) and stress (r=-0.16, p=0.42). There
was no significant correlation between motivation
scores and any of the 3 rehabilitation outcomes.
DISCUSSION
The SRMS demonstrated good inter-rater reliability
and internal consistency. There was some variability
in the item-to-total correlations between the 2
assessments, although intra-class correlations were
generally acceptable.
The mean 7-item SRMS score was 24.1, which
was greater than the cut-off score (21) for normal-
to-high motivation. The results from this pilot study
were encouraging, but further studies with a larger
sample size are required to determine whether a 28-
item or 7-item SRMS can reliably predict whether a
patient with a low motivation score is also likely to
be depressed, anxious, or stressed while undergoing
rehabilitation for stroke.
84 Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012
Table 4
and stress
Anxiety (n=31) Depression Stress (n=31)
(n=31)
6.2 (3.0-11.2) 3.0 (1.0-4.3) 4.0 (2.0-5.0) 7.0 (3.0-15.5)
-0.03 -0.01 -0.24 -0.16
0.88 0.95 0.21 0.42
The 28-item and 7-item SRMS did not predict
rehabilitation outcomes. The results of the 7-item
SRMS did not demonstrate any significant correlation
between stroke motivation scores and anxiety,
depression, or stress. There was also no significant
correlation with stroke motivation and rehabilitation
outcome measures.
Almost all participants had improved
rehabilitation outcomes. This could be a confounding
factor secondary to patient sampling. Patients were
encouraged by doctors, nurses, and physiotherapists
to actively participate in rehabilitation. Hence,
patients with low motivation were benefiting from
their treatment environment and thus obtaining
positive rehabilitation outcomes. The en masse
improvement could represent a selection bias. Bias
may have occurred in lower motivation patients
who did not want to participate in, or were excluded
from the study, leaving a group of better motivated
patients, and hence the finding of a lack of difference
in rehabilitation outcomes. The sample size may
mean the current study was underpowered to
identify small but significant differences, which may
be clarified by further larger scale studies.
CONCLUSION
The reliability of the 28-item SRMS suggests
that adaptation of the SRMS from the SMS was
successful. However, no conclusion can be made
about the validity of the SRMS.
ACKNOWLEDGEMENTS
We thank WT Hung for providing advice on statistical
analysis, and RL Whiting for assisting with patient
selection and assessment.

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APPENDIX 1
The 28-item Stroke Rehabilitation Motivation Scale (SRMS-28)*

Patient name ID Date / /

We are looking at the reasons people have for doing rehabilitation after stroke. Id like you to tell me how much these statements
represent your reasons for participating in Rehabilitation. Try not to answer yes or no, but rather in the terms below.

Completely disagree Somewhat disagree Neither agree nor disagree Somewhat agree Completely agree

1 2 3 4 5

1. Do you feel rehabilitation will help you to recover from your stroke?
1 2 3 4 5
2. Do you feel as if you wont be able to recover from your stroke?
1 2 3 4 5
3. Do you feel rehabilitation will teach you what you need to know to recover?
1 2 3 4 5
4. Do you want to show the doctors how quickly you can recover from your stroke?
1 2 3 4 5
5. Do you feel like youre being pressured to participate in the rehabilitation program?
1 2 3 4 5
6. Do you like participating in the rehabilitation program?
1 2 3 4 5
7. Does it feel satisfying to perform some of the difficult tasks in the rehabilitation program?
1 2 3 4 5
8. Do you feel bad if you dont make an effort during rehabilitation?
1 2 3 4 5
9. Do you think you are not/were not ready to begin the rehabilitation process?
1 2 3 4 5
10. Do you like learning new ways of recovering from your stroke?
1 2 3 4 5
11. Do you want to show your family members how quickly you can recover from your stroke?
1 2 3 4 5
12. Do you perform rehabilitation because it is what the doctors and therapists want you to do? (Question 4)
1 2 3 4 5
13. Do you find participating in rehabilitation exciting? (Question 2)
1 2 3 4 5
14. Does rehabilitation help you feel like youre achieving something? (Question 3)
1 2 3 4 5
15. Does rehabilitation make you feel good about yourself?
1 2 3 4 5
16. Do you ever feel like you cant quite reach your goals in rehabilitation?
1 2 3 4 5
17. Do you want to find out how much improvement you can achieve through rehabilitation?
1 2 3 4 5
18. Do you participate in rehabilitation because other stroke patients in the hospital are getting better through rehabilitation?
(Question 1)
1 2 3 4 5
19. Do you feel that your relatives or carers support you in your recovery from your stroke?
1 2 3 4 5
20. Do you find rehabilitation to be fun?
1 2 3 4 5
21. Do you feel that rehabilitation helps you to improve some of your weaknesses?
1 2 3 4 5
22. Do you feel that you have no choice but to participate in rehabilitation? (Question 5)
1 2 3 4 5
23. Do you feel like your motivation for participating in rehabilitation has gotten lower? (Question 6)
1 2 3 4 5
24. Do you feel like you are learning useful things that you could use outside hospital? (Question 7)
1 2 3 4 5
25. Do you do rehabilitation because the doctor told you to?
1 2 3 4 5
26. Do you feel that starting rehabilitation as soon as possible has allowed/will allow you to recover faster?
1 2 3 4 5
27. Do you feel good when doing your rehabilitation?
1 2 3 4 5
28. Do you want to do well in your rehabilitation program?
1 2 3 4 5
* Items in bold are selected for the 7-item SRMS

86 Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012

 Validation of the Stroke Rehabilitation Motivation Scale

APPENDIX 2
Corresponding question numbers in the Sports Motivation Scale (SMS) and the 28- and 7-item Stroke Rehabilitation
Motivation Scales (SRMS)

Subscale SMS 28-item SRMS 7-item SRMS

Amotivation 3 23 6
5 2 -
19 9 -
28 16 -
Extrinsic Motivation Regulation 6 25 -
10 4 -
16 18 1
22 11 -
Extrinsic Motivation Identification 7 12 4
11 26 -
17 5 -
24 19 -
Extrinsic Motivation Introjection 9 1 -
14 15 -
21 8 -
26 22 5
Intrinsic Motivation Achievement 8 7 -
12 21 -
15 14 3
20 28 -
Intrinsic Motivation Knowledge 2 3 -
4 10 -
23 17 -
27 24 7
Intrinsic Motivation Stimulation 1 6 -
13 13 2
18 20 -
25 27 -

Asian Journal of Gerontology & Geriatrics Vol 7 No 2 December 2012 87