the effects of motivating interventions on rehabilitation outcomes in children and youth with...

http://informahealthcare.com/bijISSN: 0269-9052 (print), 1362-301X (electronic)

Brain Inj, 2014; 28(8): 1022–1035! 2014 Informa UK Ltd. DOI: 10.3109/02699052.2014.890747

REVIEW

The effects of motivating interventions on rehabilitation outcomes inchildren and youth with acquired brain injuries: A systematic review

Sandy K. Tatla1,2, Karen Sauve3, Tal Jarus2, Naznin Virji-Babul3, & Liisa Holsti2

1Sunny Hill Health Centre for Children, Vancouver, BC, Canada, 2Department of Occupational Science and Occupational Therapy, and 3Department

of Physical Therapy, Faculty of Medicine, University of British Columbia, BC, Canada

Abstract

Primary objective: To systematically review the evidence of the effects of motivatingrehabilitation interventions on outcomes in children with acquired brain injury (ABI).Methods: A literature search of six databases was conducted to identify intervention studiespublished until July 2013. The American Academy for Cerebral Palsy and DevelopmentalMedicine (AACPDM) systematic review methodology was used as a framework. Two reviewersindependently extracted data and assessed level of evidence and quality of studies.Results: Of 891 records initially retrieved, 166 were screened by abstract and 31 by full text;10 studies comprised of five randomized controlled trials, two case series and three singlesubject research design studies met the inclusion criteria. Studies fell into three interventioncategories: (1) token economy based interventions; (2) virtual reality (VR); and (3) memory andattention interventions.Conclusions: A paucity of evidence has examined the effects of rehabilitation interventions witha motivational component. Token economies can significantly enhance memory and responseinhibition performance in children with ABI. VR systems are motivating, yet findings are limitedby the lack of use and availability of psychometrically evaluated measures of motivation.Findings point to the need for further research to evaluate the effects of motivation-basedinterventions.

Keywords

Brain injury, motivation, paediatrics, therapy

History

Received 8 November 2013Revised 14 January 2014Accepted 28 January 2014Published online 26 March 2014

Introduction

Acquired brain injury (ABI) is the leading cause of death and

disability in children and can result in persistent and

debilitating deficits that impact a child’s physical, cognitive

and psycho-emotional functioning [1]. Resulting from

damage to the brain occurring after 3 months of age, ABI

can be classified as a traumatic brain injury (TBI), caused by

trauma to the brain, or a non-traumatic brain injury (NTBI),

due to medical pathology, such as stroke, encephalitis,

anoxis, etc. [2].

After neurological insult, intensive practice is highlighted

as a key component to promote adaptive neuroplasticity.

Notably, the dose of repetitive practice required to induce

permanent neuroplastic changes is estimated to be in the

thousands [3]. Attaining these intensive dosages of therapy

can be emotionally and physically taxing for children with

ABI. An increasing awareness of the importance of consider-

ing factors in addition to practice, including attention,

motivation and salience, is apparent. Indeed, each of these

three factors has been identified as an important modulator of

neuroplasticity [4]. After childhood brain injury, family

support systems and rehabilitation approaches can facilitate

factors, such as a child’s motivation and attention, to promote

levels of intensive practice and adherence to therapy required

to produce neuroplastic changes for recovery [5]. A survey

conducted with 174 physicians, psychologists and therapists

working in ABI rehabilitation found that, in addition to

cognition and awareness deficits, motivation was among the

top three most frequently mentioned factors perceived to

influence learning in patients [6]. Moreover, lack of motiv-

ation is cited as a key limitation to children achieving their

functional potential in rehabilitation [7, 8].

Neural areas involved in motivation involve distributed,

integrated and inter-dependent systems [9]. Animal and

human studies have demonstrated relationships between

particular systems, including the ventral striatum, involved

in reinforcement learning, the orbitofrontal cortex region,

which has been linked to value judgement and decision-

making, and the anterior-cingulate cortex and the dorso lateral

prefrontal cortex regions, both of which have been associated

with executive function and cognition [9–12].

Recognizing theoretically the critical role of motivation in

optimizing rehabilitation outcomes, this review sought to

examine what is known in the literature about the effects

of motivating interventions on rehabilitation outcomes in

Correspondence: Sandy K. Tatla, MSc Candidate, MOT, OccupationalTherapist, Sunny Hill Health Centre for Children, 3644 Slocan Avenue,Vancouver, BC, Canada, V5M 3E8. Tel: 604-453-8300. Fax: 604-453-8301. E-mail: [email protected]

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children with ABI. The International Classification of

Functioning, Disability and Health (ICF) views motivation

as a general mental body function, specifically an energy and

drive function that causes an individual to move toward

satisfying specific needs and general goals in a persistent

manner [13]. A motivational rehabilitation intervention is

defined as one that promotes the initiation and persistence of

goal-directed behaviour. The current state of evidence in the

area of motivational interventions is summarized along with

recommendations for future research and implications for

clinical practice.

Methods

The American Academy for Cerebral Palsy and

Developmental Medicine (AACPDM) systematic review

methodology was applied as a framework through all

review phases. This methodology was developed to address

specifically the issues presented by the research literature on

interventions for people with complex developmental dis-

abilities [14]. This methodology provides levels of evidence

for both group and single subject research design studies and

an explicit strategy for examining outcomes from the ICF

perspective, including possible linkages of effects across ICF

components [15].

Inclusion criteria

Studies were included if: (1) participants were diagnosed with

a moderate-to-severe ABI and were aged 3 months to 18

years, (2) the intervention included a purportedly motivational

component in a rehabilitation setting and (3) motor, cognitive

and/or motivational outcomes were measured.

Studies were excluded if the participants with ABI

comprised less than 30% of the patient population.

Literature search and results

The literature search only considered studies in or translated

to English that were published in peer-reviewed journals and

included in the following electronic databases: Cumulative

Index to Nursing and Allied Health Literature (CINAHL)

1982 to July 2013, EMBASE 1946 to July 2013 (Ovid) and

PsycINFO (EBSCO), MEDLINE 1946 to July 2013 (Ovid),

the Cochrane Database of Systematic Reviews and the

Cochrane Central Register of Controlled Trials. Electronic

search terms included a combination of ‘motivation’,

‘achievement’, ‘goals’, ‘volition’, ‘engagement’, ‘success’,

‘brain injury’, ‘brain contusion’, ‘encephalopathy’, ‘stroke’,

‘rehab’, ‘function’, ‘train’, with child limits set for all

searches. Further literature was obtained by exploring the

reference lists of studies and by reviewing articles related

to included papers. See the Appendix for a record of the

search strategy.

The initial database search yielded 888 articles. All

articles were screened by title and three additional articles

were added through hand searching. One hundred and sixty-

six articles were screened by abstract, with 31 articles

examined by full text, and studies were excluded for reasons

described in Figure 1. Thus, a total of 10 studies remained

for analysis.

Data extraction and organization

Two reviewers screened for inclusion, extracted data, rated

levels of evidence (Table I), appraised study quality (Table II)

and classified outcomes according to the ICF. Reviewers

independently appraised level of evidence (LoE), study

quality for LoE I–III studies and the classification for ICF,

then discussed and resolved in cases of initial differences in

classification. When required, authors were contacted to

gather additional information not reported in the article.

Summary of findings

Study types, participants and interventions (Tables IIIand IV)

This body of evidence comprises seven group studies and

three single subject research studies (SSRDs). Four group

research designs capable of producing level I evidence

received a weak quality rating and one level II study received

a moderate quality rating (Table III). In addition, one SSRD

capable of producing level I evidence received a strong rating

(Table IV). The remaining four studies produced level IV and

V evidence, but this level of evidence is insufficiently robust

to include in the evidence table for analysis. Nevertheless,

these studies provide useful information as pilot data for

future research.

Of the 507 children included in the studies, there were

241 children and youth with moderate-to-severe ABI.

Mixed into the samples were 191 children with orthopaedic

injury (OI), 31 children with attention deficit/hyperactivity

disorder (ADHD), 26 children acting as healthy controls,

15 children with mild TBI and a single child with

meningomyelocele or upper plexus paresis or Guillian

Barre. Participants’ ages ranged from 6–16 years and the

sample included 343 males and 164 females. The higher

proportion of males represented in this sample is consistent

with higher incidence rates of ABI amongst males in the

general population (68%) [16].

The experimental or motivational interventions are cate-

gorized within the environmental component of the ICF.

In six of the 10 studies, the motivational component was a

reward contingency in the form of a product used for play (i.e.

small toy) or a financial asset (i.e. products, such as dollars or

pennies) or support and relationships through praise from

health professionals. The rewards were presented when

participants successfully performed the tasks in each respect-

ive study. In four studies the motivational condition was

manipulated such that either pennies (low motivation) or

dollars (high motivation) were given for successful perform-

ance during an event-based memory task [12, 17–19].

In another study, toys, sweets or verbal feedback were given

to participants for successful response inhibition during a

computer task [20]. Lastly, in an SSRD, points and money

were offered to participant’s contingent upon their attendance

to therapy [21].

In three studies, the motivational component was a

technological product made available; specifically, a virtual

reality (VR) component. VR is an interactive computer-based

environmental system that presents artificially generated

sensory information [22]. These studies assessed motivation

DOI: 10.3109/02699052.2014.890747 Motivation in children with brain injury 1023

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and other outcomes using a rehabilitation-specific system, the

paediatric interactive therapy system (PITS) [23], or com-

mercially available consoles, including the Nintendo Wii-Fit

[24, 25] and the X-Box Kinect [25]. Finally, the motivational

component in one study consisted of an assistive product for

education, a memory and attention training programme for

children designed to be integrated into school and maintain

the child’s motivation while improving his/her memory,

attention and executive functioning skills [26].

Outcomes, measures and results

The outcomes of interest were memory, attention, motor and

energy and drive/motivation outcomes (Tables VII and VIII).

Figure 1. Search strategy results for studies evaluating the effects of motivation based interventions in children with acquired brain injury.

Table I. Levels of evidence for group and single subject research designs.

Level Intervention (group) studies Single subject design studies

I Systematic review of randomized controlled trials (RCTs)Large RCT (with narrow confidence intervals) (n4100)

Randomized controlled N-of-1 (RCT), alternating treatment design(ATD) and concurrent or non-concurrent multiple baseline design(MBDs); generalizability if the ATD is replicated across three ormore subjects and the MBD consists of a minimum of threesubjects, behaviours or settings. These designs can provide causalinferences.

II Smaller RCTs (with wider confidence intervals) (n5100)Systematic reviews of cohort studies‘Outcomes research’ (very large ecologic studies)

Non-randomized, controlled, concurrent MBD; generalizability ifdesign consists of a minimum of three subjects, behaviours, orsettings. Limited causal inferences.

III Cohort studies (must have concurrent control group)Systematic reviews of case control studies

Non-randomized, non-concurrent, controlled MBD; generalizability ifdesign consists of a minimum of three subjects, behaviours orsettings. Limited causal inferences.

IV Case seriesCohort study without concurrent control group (e.g. with

historical control group)Case-control study

Non-randomized, controlled SSRDs with at least three phases (ABA,ABAB, BAB, etc.); generalizability if replicated across three ormore different subjects. Only hints at causal inferences.

V Expert opinionCase study or report. Bench researchExpert opinion based on theory or physiologic researchCommon sense/anecdotes

Non-randomized controlled AB SSRD; generalizability if replicatedacross three or more different subjects. Suggests causal inferencesallowing for testing of ideas.

1024 S. K. Tatla et al. Brain Inj, 2014; 28(8): 1022–1035

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In eight of the 10 studies, outcomes were evaluated in a

motivational condition compared to a control condition

consisting of traditional therapy or incentives considered to

be less motivating. Two studies did not have a comparison

intervention, rather evaluated the effects of the motivating

intervention alone [23, 26]

Four of the 10 studies were randomized cross-over trials

measuring event-based prospective memory performance

(EB-PM) during two sessions of neuropsychological testing

in children at various intervals post-mild TBI, moderate-to-

severe TBI or orthopaedic injury (OI) [12, 17–19].

Participants underwent the same activity in both sessions,

receiving either pennies or dollars for correctly remembering

to ask for points when an EB-PM cue was given to them

during each session. In another randomized control trial,

reaction time was measured in children with ADHD, mod-

erate-to-severe TBI and healthy children while they under-

went two sessions of a computer activity and randomly

received either a reward contingency, such as praise, toys or

sweets or no reward contingency when correctly performing

the stopping behaviour upon receiving a stop signal cue [20].

In two SSRD studies, children with ABI underwent

varying lengths of Wii Fit, Kinect or traditional balance

therapy during OT or PT for 30 minutes over a 4-week

intervention [24, 25]. Motivation to participate in therapy and

dynamic and static balance were measured after each session,

with weekly assessment of participants’ functional abilities.

In a pilot case series study, clients’ motivation to participate

in VR-based occupational therapy was measured after every

session and upper limb function was assessed before and after

the 3-week intervention [23]. Lastly, investigators evaluated

participants’ memory, attention and executive function skills

in school-aged children with ABI, before and after completing

a daily 45-minute attention and memory-training programme

[26]. The child’s motivation to participate in therapy was

measured daily over the 20-week intervention.

Evidence table

Table IX aggregates the evidence, which is limited to the

results of studies capable of producing Levels I–III evidence,

as Level IV and V results are insufficiently robust to inform

clinical practice. Results are presented according to ICF

categories and indicators based on the strength of the

evidence.

Analysis and discussion of the evidence

(1) What evidence exists about the effects of motivating

interventions for children and youth with moderate-

to-severe ABI on outcomes representing components of

the ICF?

Body functions

Memory functions

In children with moderate TBI, findings from three studies

demonstrate that extrinsic motivators in the form of monetary

incentives result in significantly greater prospective memory

performance during the sub-acute phase of recovery (level

I–W) [19] or 3 months post-injury [17] or 1 year post-injury

[12]. However, in children with severe TBI, monetary

incentives significantly improved prospective memory per-

formance only 1 year post-injury [12], with non-significant

improvements during the sub-acute phase [19] and 3 months

Table II. Conduct questions of group and single subject research design studies with levels of evidence I, II or III.

Group study conduct questions1. Were inclusion and exclusion criteria of the study population well described and followed?2. Was the intervention well described and was there adherence to the intervention assignment? (for 2-group designs, was the control exposure also

well described?) Both parts of the question need to be met to score ‘yes’.3. Were the measures used clearly described, valid and reliable for measuring the outcomes of interest?4. Was the outcome assessor unaware of the intervention status of the participants (i.e. were the assessors masked)?5. Did the authors conduct and report appropriate statistical evaluation including power calculations? Both parts of the question need to be met to

score ‘yes’.6. Were dropout/loss to follow-up reported and less than 20%? For 2-group designs, was dropout balanced?7. Considering the potential within the study design, were appropriate methods for controlling confounding variables and limiting potential biases

used?

Single subject study conduct questions1. Was/were the participant(s) sufficiently well described to allow comparison with other studies or with the reader’s patient population?2. Were the independent variables operationally defined to allow replication?3. Were intervention conditions operationally defined to allow replication?4. Were the dependent variables operationally defined as dependent measures?5. Was inter-rater or intra-rater reliability of the dependent measures assessed before and during each phase of the study?6. Was the outcome assessor unaware of the phase of the study (intervention vs. control) in which the participant was involved?7. Was stability of the data demonstrated in baseline, namely lack of variability or a trend opposite to the direction one would expect after

application of the intervention?8. Was the type of SSRD clearly and correctly stated, for example, A–B, multiple baseline across subjects?9. Were there an adequate number of data points in each phase (minimum of five) for each participant?10. Were the effects of the intervention replicated across three or more subjects?11. Did the authors conduct and report appropriate visual analysis, for example, level, trend and variability?12. Did the graphs used for visual analysis follow standard conventions, for example x- and y-axes labelled clearly and logically, phases clearly

labelled (A, B, etc.) and delineated with vertical lines, data paths separated between phases, consistency of scales?13. Did the authors report tests of statistical analysis (e.g. celeration line approach, two-standard deviation band method, C-statistic, etc.?)14. Were all criteria met for the statistical analyses used?

Group Study Quality Rating: Weak (W): 1–3; Moderate (M): 4–5; Strong (S): 6–7.Single Subject Quality Rating: Weak (W):57; Moderate (M): 7–10; Strong (S): 11–14.


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Tab

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8–

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feed

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po

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(co

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ed)


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post injury (level I–W) [19]. In addition, findings of a study

examining brain behaviour relations suggest that particular

white matter structures known to be important in prospective

and episodic memory functioning and reward processing

(cingulum bundles, orbitofrontal white matter and uncinate

fasciculi) are damaged in individuals with moderate-to-severe

TBI; this outcome was found to correlate with participants’

motivation based EB-PM performance, such that greater

damage in these white matter structures was associated

with poorer performance in highly motivating conditions

(level I–M). No significant correlation was found between the

extent of damage and performance in less motivating

conditions [18].

Response inhibition

A single RCT indicates that children with moderate-to-severe

TBI significantly improved their performance during a

stopping task in the presence of external motivators involving

praise, toys or sweets, with weak-to-moderate effects

(!2¼ 0.16). However, children with TBI were less responsive

to these extrinsic motivators in comparison to children with

ADHD, who showed large effects (!2¼ 0.47) in response to

reward reinforcement (level II–W) [20].

Energy and drive functions: Motivation

A single SSRD (level I–S) showed that youth were highly

motivated during a Wii-Fit balance intervention. However, a

basic effect (indicating significantly greater results in the

treatment intervention) was observed only in one of three

participants, with both of the other participants demonstrating

equal levels of motivation during Wii and traditional balance

therapy [24].

Although level IV and level V evidence contains too much

bias to be confident in the validity of findings, studies

comprising these categories provide some indication for

outcomes of interest that have not been studied in a more

robust manner. With regard to motivation, findings from one

level IV study indicate that participants were motivated

during rehabilitation using a rehabilitation-specific VR

system [23]. Another level IV study reported anecdotal

evidence from parents, teachers and children with TBI

indicating that the children were motivated to start training

each day of a memory and attention programme [26]. Finally,

a level V SSRD demonstrated that a client was consistently

highly motivated during Wii-Fit balance therapy, but that

motivation fluctuated when using the X-Box Kinect for

balance rehabilitation [25].

Activity

Dynamic balance

Evidence from a single SSRD (level I–S) indicates mixed

results regarding changes in dynamic balance during a Wii-Fit

balance intervention compared to traditional therapy [24].

Dynamic balance performance measured by the Timed Up

and Go assessment [27] was greater for two of three

participants, during Wii-Fit therapy in comparison to trad-

itional balance therapy; however, participants demonstrated

mixed results when balance was assessed using the ModifiedCit

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Functional Reach Test (MFRT) [28], with all partici-

pants displaying significant improvement on the MFRT

sub-test involving side reaching using their unaffected

arm [24].

Static balance

Static balance results were inconclusive in the level I (S)

SSRD because reliable readings could not be obtained for all

participants using a centre of pressure measure on the Wii-Fit

Balance Board [24].

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findings of a single level I SSRD, preliminary findings

from the levels IV–V evidence from Table II will also be

mentioned. A rehabilitation-specific VR intervention showed

significant improvements in upper limb functioning on one of

three upper limb measures, the Box and Block Test [23].

In addition, a level V SSRD showed positive trends for

Table IV. Summary of studies: Intervention and participants (single subject research studies).

Citations PurposeLOE, quality andresearch design Participants Total n

Ages(years) Intervention

Tatlaet al. [21]

To evaluate the effec-tiveness of theNintendo Wii com-pared to traditionalbalance therapy inimproving balance,motivation and func-tional ability in chil-dren with ABI

I–S (11/14)Non-concurrent,

randomized mul-tiple baselinedesign

Youth within 1 year ofABI undergoinginpatientrehabilitation

n¼ 3(TBI and stroke)

12–14 Motivating intervention:Wii-Fit balance training30 minutes/day with OTor PT for 8, 12 or 15days depending on pro-tocol assigned (Phase B)

Control intervention:Traditional balance ther-apy 30 minutes/day withOT or PT for 5, 8 or 12days depending on pro-tocol assigned. Activitieswere individualizeddepending on the client’sneeds (e.g. throwing/catching beanbags/ballsoutside base of support,reaching on unstablesurfaces, side stepping,walking up/down stairs,single let stance andkicking activities)(Phase A)

Zenciuset al. [18]

To compare the effec-tiveness of threemotivational systemsfor therapy atten-dance: behaviouralcontracting, a pointsystem that wasstrictly reinforcingand a point systemplus response costs

IV- A-B-AMultiple treatment

design

Adolescents receivinginpatient rehabilita-tion post-ABI

n¼ 2 (TBI) 16 Motivating intervention:Adolescents prompted toattend therapy sessionsusing different types ofcontingencies:� Behavioural contract-ing (Phase B)� Point system (Phase C)� Point system plusmonetary incentive(Phase D)

Control intervention:Baseline with no contin-gencies for attendingtherapy (Phase A)

Cheunget al. [22]

To explore the effect ofX-box Kinect onimproving balanceand motivation inone child with anABI

VNon-randomized

controlled SSRD

Youth within 1 year ofABI undergoinginpatientrehabilitation

n¼ 1 (Stroke) 10 Motivating intervention:VR balance training for30 minutes/day with OTor PT, using X-BoxKinect Adventures andKinect Sport games (8days) and Nintendo WiiFit games (7 days).

Control intervention:Traditional balance ther-apy 30 minutes/day withOT or PT for 5 days.Activities included:standing reaches (high/low), throwing/catchingbeanbags, side steppingand walking.

LOE, Level of Evidence; ABI, Acquired brain injury; OT, occupational therapy; PT, physiotherapy; VR, Virtual Reality.


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improvements in both static and dynamic balance for both

Kinect and Wii-Fit interventions in comparison to traditional

balance therapy for one youth with an ABI [25]. Finally,

extrinsic motivators in the form of points and monetary

incentives resulted in higher attendance rates in therapy for

two individuals with an ABI [21].

Other components of the ICF

The potential effects of motivational interventions on body

structures and participation were not investigated in this body

evidence. In three of the studies exploring EB-PM, environ-

mental and personal factors were examined to determine if

significant differences were present within the sample of

participants and none were found [12, 17, 19].

(1) What evidence exists for linkages of effects within and

between these ICF components?

Investigators did not explicitly study linkages between

components of the ICF and this body of evidence is too

limited to examine any effects across these categories.

(2) What kinds and magnitude of adverse events have been

reported?

Two studies reported the presence of adverse events during

the intervention and found none [24, 25]. All other studies did

not report in this area.

(3) What is the strength of the evidence?

The body of evidence exploring the effects of motivational

interventions on rehabilitation outcomes in children with ABI

is scarce. Nevertheless, it is positive that five out of 10 studies

employed rigorous designs representing level I and II

evidence. Four group studies were assigned ratings of level

I evidence; with weak or moderate quality ratings and one

level II study received a weak quality rating (Table V). One

SSRD received a strong quality rating (Table VI).

Methodological shortcomings of studies included (1) insuf-

ficient description of adherence to intervention assignment;

(2) lack of reporting about outcome measures, including

measures of motivation; (3) lack of use of valid and reliable

measures; (4) lack of assessor blinding to intervention status

of participants; and (5) with the exception of the studies by

McCauley et al. [12, 17–19], sample sizes in studies were

notably limited. Further potential areas for improvement

include blinded assessors where feasible and more thorough

reporting about outcome measures, including those related to

motivation and cognitive outcomes.

While four level IV and V evidence studies offer little to

inform evidence-based practice in terms of evaluating inter-

vention effectiveness for balance [25], upper limb function

[23], therapy attendance [21] and memory and attention [26],

this research provides preliminary evidence that can lay the

foundation for more robust research designs and can be used

to establish treatment or evaluation protocols for larger

studies.

Summary and directions for future research

A paucity of evidence has explored the motivational compo-

nent of rehabilitation interventions and its effects on rehabili-

tation outcomes in children and adolescents with ABI. The

findings from this review reveal a body of evidence that is

comprised of studies which fall into three categories: (1)

studies that have applied token economies as extrinsic

motivators and measured the impact on outcomes in com-

parison to a control treatment without incentives [12, 17–21];

(2) studies that measured participant motivation during virtual

reality interventions alone [23] or in comparison to traditional

therapy [24, 25] to determine effects of the intervention on

rehabilitation outcomes; and (3) a single study that measured

participant motivation and other outcomes during a memory

and attention intervention [26].

The presence of level I and II evidence that has explored

the application of token economy systems is promising

because it provides a basis for inferring the impact of

incentives on rehabilitation outcomes for individuals with

ABI. Findings from these studies indicate that, while children

and adolescents with moderate TBI benefit from the use of

incentives to enhance prospective memory performance

during the sub-acute phase or 1-year post-injury, individuals

with severe TBI benefit from incentives 1-year post-injury

only. Brain imaging findings also show that damage to brain

regions involved in both memory and motivation is greater in

those with more severe TBI. In the area of response

inhibition, level II (M) evidence from one study indicates

that children with moderate-to-severe TBI benefit from token

economies to significantly improve their responsiveness to

stopping tasks, when prompted; however, they show less

Table V. Conduct of group design studies for studies with levels of evidence I, II or III.

Study Level/quality 1 2 3 4 5 6 7

McCauley et al. [12] I-W (3/7) Yes No No No No Yes YesMcCauley et al. [19] I-W (3/7) Yes No No No No Yes YesMcCauley et al. [17] I-W (3/7) Yes No No No No Yes YesMcCauley et al. [18] I-M (4/7) Yes No Yes No No Yes YesKonrad et al. [20] II-W (3/7) Yes No No No No Yes Yes

W, Weak: 1–3; M, Moderate: 4–5; S, Strong: 6–7.

Table VI. Conduct of single subject research design studies for studies with levels of evidence I, II or III.

Study Level/quality 1 2 3 4 5 6 7 8 9 10 11 12 13 14

[21] I-S (11/14) Yes Yes Yes Yes No Yes No Yes Yes No Yes Yes Yes Yes

W, Weak:57; M, Moderate: 7–10; S, Strong: 11–14.


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Table VII. Summary of studies: Outcomes, measures and results (group studies, levels I–V).

StudyOutcomeof interest

ICFcomp Measure Result Statistics LOE

McCauley et al. [12] EB-PM Performance BF Total # points collectedduring session (Exp)

+OI p¼ 0.00 I + W

BF Total # points collectedduring session (Exp)

+Mild TBI p50.02 I + W


+STBI p50.00 I + W


OI4STBI p50.00 I + W


Mild TBI4STBI p¼ 0.00 I + W

BF Total # points collectedduring session (Ctl)



Mild TBI4STBI p50.00 I + W

Age & EB-PMPerformance

PF Age in years Older4younger p¼ 0.02 I + W

Gender & EB-PMPerformance

PF Sex NS I + W

Socioeconomic status EF SocioeconomicComposite Index

NS I + W


+OI p50.00, d¼ 0.59 I + W


+MTBI p50.03, d¼ 0.44 I + W


+STBI NS, d¼�0.12 I + W


OI4MTBI p¼ 0.08 I + W




MTBI4STBI p50.03 I + W


OI4MTBI NS I + W


OI4STBI p¼ 0.00 I + W


MTBI vs. STBI NS I + W


PF Age in years Older4younger p50.02 I + W


PF Sex NS I + W


NS I + W


+OI p¼ 0.00, d¼ 0.68 I + W


+MTBI p50.03, d¼ 0.69 I + W


+STBI NS, d¼ 0.22 I + W


OI4MTBI NS I + W




MTBI4STBI p50.01 I + W


OI4MTBI NS I + W


OI4STBI p¼ 0.00 I + W


MTBI4STBI NS I + W


PF Age in years Older4younger p¼ 0.03 I + W


PF Sex NS I + W


NS I + W

(continued )


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responsiveness to these extrinsic rewards than children with

ADHD. Collectively, these findings suggest a potential link

between aetiology and response to extrinsic motivators and

that the effects of motivational incentives may vary based on

the severity of brain injury. These findings justify the need for

future research to explore links between aetiology, brain

injury severity and motivational performance, as limited

research has explored these relationships. While the afore-

mentioned studies demonstrate the beneficial effects of

incentives on individuals with moderate-to-severe TBI, each

interventions was completed over only two sessions of 1-hour

duration. Therefore, further research is needed to determine

the effects of these types of incentives on sustaining client

motivation for tasks carried out over a longer duration.

Furthermore, the application of incentives as external motiv-

ators is debatable in rehabilitation because this form of

motivation does not necessarily promote patients’ intrinsic

motivation [29]. However, in certain instances, applying

StudyOutcomeof interest

ICFcomp Measure Result Statistics LOE

McCauley et al. [18] Neural pathologicalchanges

BF *DTI using FA in 3regions of interest

OI4M-STBI p� 0.00 I + M

Neural pathologicalchanges

BF nDTI using ADC in 3regions of interest

OI5M-STBI p� 0.00–p50.04 I + M

Neural correlates withmotivation condition

BF *DTI using FA in 3regions of interest(Exp)

+M-STBI p� 0.00 I + M

BF *DTI using FA in 3regions of interest(Exp)

OI NS I + M

BF nDTI using ADC in 3regions of interest(Exp)

�M-STBI NS I + M

BF nDTI using ADC in 3regions of interest(Ctl)

�M-STBI NS I + M

BF nDTI using ADC in 3regions of interest(Ctl)

OI NS I + M

Konrad et al. [20] Response inhibition BF Stop signal reactiontime (Exp)

+ADHD !¼ 0.47 II + W

BF Stop signal reactiontime (Exp)

+TBI !¼ 0.16 II + W


+Ctl !¼ 0.17 II + W


TBI4ADHD p¼ 0.02 II + W


TBI4Ctl p¼ 0.00 II + W


ADHD4Ctl NS II + W

BF Stop signal reactiontime (Ctl)

TBI4ADHD NS II + W


TBI4Ctl p50.00 II + W


ADHD4Ctl p¼ 0.03 II + W

Wille et al. [23] Motivation BF Unknown + VUpper limb function A/P MUUL + NS IVUpper limb function A/P Box and Block Test + p¼ 0.03 IVFine motor dexterity A/P Nine Hole Peg Test + NS IV

Sjo et al. [26] Motivation BF Did child want to starttraining each day?

+ IV

Cognition BF WISC-III ± IVBF NASC ± IV

Attention BF TEA-Ch ± IVExecutive functioning BF BRIEF ± IV

ADC, apparent diffusion coefficient; A/P, Activities & Participation; BF, Body Functions; BRIEF, Behaviour Rating Inventory of Executive Function;Comp, Component; DTI, Diffusion tensor imaging; EB-PM, Event based prospective memory; EF, Environmental Factors; FA, fractional anisotropy;MTBI, moderate traumatic brain injury; M-STBI, moderate-to-severe traumatic brain injury; MUUL, Melbourne Assessment of Unilateral UpperLimb Function; NASC, Neurological Assessment of the School-Aged Child; NS, Not significant; OI, Orthopaedic injury; PF, Personal Factors; STBI,severe traumatic brain injury; TEA-Ch, Test of Everyday Attention for Children; WISC-III, Wechsler Intelligence Scale for Children III.

*FA ranges from 0–1, with lower diffusion indicative of more severe injury. Three regions of interest include: cingulum bundles, orbitofrontal whitematter and uncinate fasciculi.

n: ADC ranges from 0–1 and is inversely proportional to FA. Higher diffusion indicative of more severe injury. Three regions of interest include:cingulum bundles, orbitofrontal white matter and uncinate fasciculi.

(+), improved results; (�), worse results; (±), mixed results.


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external reinforcers may be the only way to motivate a client,

such as conditions in which a client’s executive functioning

deficits limit his/her capacity to maintain and regulate levels

of motivation. Whenever possible, it would be useful to

develop a plan to support reinforcement fading so that a child

can independently be motivated to promote self-sustaining

behaviour [30].

Three studies evaluated the effects of VR systems,

including the Nintendo Wii, the X-box Kinect (level

V-SSRD) and a rehabilitation-specific system (IV-Group

study). A pilot SSRD (level I–S) reported about activity

outcomes, demonstrating promise for the use of the Nintendo

Wii as a motivating treatment for balance rehabilitation in this

population. It is important to mention that, although all

participants were motivated to use the Wii, a basic effect

demonstrating more favourable motivation results towards the

Wii vs. standard balance therapy was only reported in one of

three participants. Moreover, the remaining studies examining

activity outcomes are represented by level IV and V evidence,

thus findings in this important area should be considered

preliminary.

Gamification literature, which applies principles of token

economies and extrinsic motivators as a mechanism to

promote adherence and behaviour change, often includes

video game consoles [31]. Some have suggested that

promoting sustained behaviour requires intrinsic or internally

regulated rather than other forms of extrinsic motivation [29]

and literature has begun to examine how gaming may promote

intrinsic motivation [31]. An understanding of intrinsic

motivation involves a consideration of factors, such as

competence, mastery, self-control, achievement and self-

efficacy and, while these factors may be heightened in healthy

Table VIII. Summary of studies: Outcomes, measures and results (single subject research studies, levels I–V).

Study Outcome of interest ICF Comp Measure Result LOE

Tatla et al. [24] Motivation BF Study-specific VAS (Therapy) + I + SBF Study-specific VAS (Wii) + I + S

Dynamic Balance A/P Timed Up and Go (Therapy) + I + SA/P Timed Up and Go (Wii) + I + SA/P MFRT (Therapy) ± I + SA/P MFRT (Wii) ± I + S

Functional Abilities A/P PEDI (Therapy) + I + SA/P PEDI (Wii) + I + S

Zencius et al. [21] Motivation to attend therapy A/P Therapy Attendance (No incentive) � IVA/P Therapy Attendance (Points) + IVA/P Therapy Attendance (Points + Monetary) + IV

Cheung et al. [25] Motivation BF Study-specific VAS (Therapy) + VBF Study-specific VAS (Kinect) ± VBF Study-specific VAS (Wii) + VA/P Timed Up and Go (Therapy) + VA/P Timed Up and Go (Kinect) + V

Dynamic Balance A/P Timed Up and Go (Wii) + VA/P MFRT (Therapy) � VA/P MFRT (Kinect) + VA/P MFRT (Wii) + V

Static Balance A/P Centre of Pressure (Therapy) + VA/P Centre of Pressure (Kinect) + VA/P Centre of Pressure (Wii) + V

A/P, Activities & Participation; BF, Body Functions; Comp, Component; EF, Environmental Factors; MFRT, Modified Functional Reach Test;Paediatric Evaluation of Disability Index (Caregiver Assistance and Modification Scale); PF, Personal Factors; VAS, Visual Analogue Scale; Wii,Nintendo Wii; Kinect, X-Box Kinect.

(+), improved results; (�), worse results; (±), mixed results.

Table IX. Evidence table: Outcomes of motivational interventions for children and youth with moderate-to-severe acquired brain injury (level ofevidence I, II or III).

Outcomes by ICFcomponent offunctionand disability

Improved resultswith motivational

intervention(statisticallysignificant)

Improved results withmotivationalintervention

(but not statisticallyevaluated)

Correlation withmotivationalintervention(statisticallysignificant)

Worse resultswith motivational

intervention(statisticallysignificant)

Resultsunchanged or

not statisticallysignificant

Body functionsMotivation * I + S [24]EB-PM performance I + W [12]; I + W [19]; I + W [17] I + W [19]; I + W [17]Neural correlates with

motivational conditionI + M [18]

Response inhibition II + W [20]Activities and participation

Dynamic balance * I + S [24] * I + S [24]Functional abilities * I + S [24]

EB-PM, Event based prospective memory; *Denotes SSRD.


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individuals during gaming, an understanding of how these

factors are influenced during gaming for individuals with

impairments, such as those with ABI, is not yet understood.

Indeed, applying gamification principles to human services is

one of the most challenging areas, particularly when behav-

iour change in this context is not fun and not voluntary [31].

Although the motivating features of gaming systems are cited

as a key reason for applying VR in the rehabilitation context

[32–34], they may not be as motivating as one might presume

because factors beyond intrinsic interest, such as sense of

competence and self-efficacy, may be challenged during

gaming in this population, which may hinder levels of

motivation.

Brain injuries are a highly individualized disability that

can result in a myriad of impairments [35]. Consequently,

individuals with ABI undergo a process of adjusting to their

injury and altered abilities and can face a number of barriers

that may limit their motivation for therapy. An exploratory

study found that children with TBI have significantly lower

self-esteem when compared to non-injured peers [36].

Perceived self-efficacy, which can be described in the context

of rehabilitation as a specific belief in one’s capacity to meet

the demands of treatment [37], can also be affected in

children with ABI, impacting their achievement motivation.

The complexity of factors influencing an individual’s motiv-

ation after ABI makes it pertinent to apply motivation

theories when examining this construct in the context of

therapeutic interventions. Self Efficacy Theory, Self

Determination Theory, the Flow Model, Expectancy-Value

Theory and Achievement Goal Theory are examples of

theories that can be applied in this context [29, 38–40]. The

application of theoretical frameworks when evaluating client

motivation in the context of rehabilitation would strengthen

the knowledge base in this important area.

Overall, motivation in children with ABI has received very

little attention; however, evidence applied to children with

other developmental disabilities, such as cerebral palsy, is

emerging [38, 41–47]. Studies have shown that children with

developmental disabilities tend to have lower levels of

mastery motivation compared to their peers and that higher

levels of motivation exist in those with higher functional and

motor abilities [47]. Furthermore, when compared to typic-

ally-developing peers, children with developmental disabil-

ities tend to be more passive and avoid complex and

challenging activities [38].

While all studies included in this review evaluated the

impact of motivational components in rehabilitation inter-

ventions, studies that applied token economies as extrinsic

motivators did not include an explicit measure of motivation

to confirm that the incentive was truly motivating. That being

said, the therapeutic application of token economies as

reinforcers has existed for over a century [48] and the studies

in this review offered rationale for selecting specific types of

extrinsic motivators. McCauley et al. [12] were the first to

explore the impact of monetary incentives on memory

performance in children with TBI and cited the provision of

pocket money/allowance for earning income for successful

work completion as a common technique for motivating

children. Nonetheless, the authors acknowledged the arbitrary

nature of selecting dollars vs. pennies as differential

motivators for the EB-PM task. In addition, Konrad et al.

[20] cited empirical evidence that supported the use of

response contingencies in children with ADHD as a founda-

tion for their response inhibition study involving children with

TBI and/or ADHD. Of the studies that included a measure of

motivation, none used a valid and reliable measure to evaluate

this construct. A visual analogue scale was used in two VR-

related studies [24, 25] and in one study no description was

provided about how motivation findings were obtained [23].

In another study, motivation was assessed through anecdotal

report; caregivers, teachers and the child were each asked how

motivated the child was to begin an attention-training

programme each day [26]. Similar to findings in a recent

systematic review examining the effects of motivational

rehabilitation interventions in children with CP, a lack of use

of psychometrically evaluated measures of motivation exists

with this population [15].

The implicit, dynamic and multifaceted nature of motiv-

ation renders it a difficult construct to measure [11]. To that

end, it is not surprising that few tools are available to measure

child’s motivation for therapy. In a recent systematic review of

motivation measures in school-aged children with a physical

disability or motor delay, Miller et al. found that, although

numerous abstracts included the word motivation, few studies

evaluated motivation with scales that had undergone psycho-

metric testing. Their search revealed two assessments that

measure motivation across contexts: the Dimensions of

Mastery Questionnaire (DMQ) [49] and the Pediatric

Volitional Questionnaire [50]. Psychometric evidence for

these measures is preliminary; however, their conscious

application by therapists can benefit the rehabilitation process

by providing a more robust picture of clients’ motivation.

While rehabilitation professionals have long recognized

that client motivation affects outcomes, little research has

been conducted on the nature of motivation [51]. Engagement

in therapy has been conceptualized as an overarching

construct that is driven by motivation and executed by the

directing of energy and effort towards a task [37]. To engage

clients in therapy and to achieve the high dosages required to

promote neuroplasticity and function, it is necessary to

examine the motivational features of rehabilitation interven-

tions. Clinicians need to attend to the complex and dynamic

relationship between task features, environmental features and

client characteristics in order to promote a match between the

motivational characteristics of the task and the environment to

the child [15]. Moreover, a need exists to evaluate client

motivation over time to determine the influence of motivation

on therapeutic outcomes. The application of psychometrically

sound measures of motivation can assist clinicians and

researchers to ascertain the extent of individual differences

and the impact of adjusting specific intervention strategies on

client motivation and the extent to which motivational

disposition can be changed over time [52].

Limitations

Keyword, multiple-database and follow-up reference searches

were conducted to extensively search the literature for articles

relevant to motivation. However, some articles that measured

motivation but that used different terms may have been


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missed because the search strategies was limited to studies in

which the authors explicitly stated that they were measuring

the effects of motivation. In addition, the exclusion of non-

English language and grey studies may be a source of bias in

this review.

Conclusions

At the level of body functions, extrinsic motivators in the

form of token economies appear to improve performance in

children with moderate-to-severe TBI. Evidence regarding the

effects of interventions on client motivation is limited to a

single, level I SSRD and a few pilot studies. No studies have

used psychometrically sound measures to assess motivation in

children with moderate-to-severe ABI. Furthermore, the

effects of motivating interventions at the activity level are

limited to a single SSRD, showing mixed findings and no

evidence about the effects of motivating interventions on

participation outcomes exists in this population.

This review reveals a need for clinicians and researchers to

explicitly apply valid and reliable measures of motivation

and/or theoretical rationale to understand motivation in the

rehabilitation context. In so doing, clinicians and researchers

can identify methods to promote engagement in rehabilitation

activities and identify if clients are, indeed, motivated during

the particular interventions under study. To that end, the

development of instruments to assess motivation in this

population is warranted.

Acknowledgements

Sandy Tatla was supported by the Child & Family Research

Institute, an agency working in close partnerships with the

British Columbia Provincial Health Services Authority and

the University of British Columbia (UBC). The authors would

like to acknowledge and thank Charlotte Beck, Clinical

Librarian, UBC, for her assistance in developing the search

strategy for this review.

Declaration of interest

The authors report no conflicts of interest. The authors alone

are responsible for the content and writing of the paper.

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Appendix: Medline search strategy

(1) motivation/or achievement/or goals/or intention/or vol-

ition/or engagement.mp. [mp¼ title, abstract, original

title, name of substance word, subject heading word,

keyword heading word, protocol supplementary con-

cept, rare disease supplementary concept, unique iden-

tifier] (100537)

(2) (motivation or achieve* or goal setting or success or

volition or engage*).mp. [mp¼ title, abstract, original

title, name of substance word, subject heading word,

keyword heading word, protocol supplementary con-

cept, rare disease supplementary concept, unique iden-

tifier] (865043)

(3) exp Brain injuries/rh (4561)

(4) (brain injur* or brain contusion* or encephalopath* or

stroke).mp. [mp¼ title, abstract, original title, name of

substance word, subject heading word, keyword heading

word, protocol supplementary concept, rare disease

supplementary concept, unique identifier] (266545)

(5) exp Stroke/rh (7494)

(6) ((brain$ or cerebr$ or cerebell$ or intracran$ or

intracerebral) adj5 (isch?emi$ or infarct$ or thrombo$

or emoboli$ or occlus$ or stroke or accident*)).tw.

(82318)

(7) 1 or 2 (877106) [Motivation]

(8) 3 or 4 (266668) [Brain injuries]

(9) 5 or 6 (89041) [Stroke]

(10) 8 or 9 (314180) [Combines brain injuries with stroke to

give both]

(11) 7 and 10 (13748) [Motivation combined with brain

injuries and stroke]

(12) rh.fs. (162193) [Rehab]

(13) 11 and 12 (1614)

(14) limit 13 to ‘all child (0–18 years)’ (243) this limits set

13 to those about children

(15) child*.mp. (1872848) [anything with child or children]

(16) 13 and 15 (116) [anything with child or children is

combined with motivation and brain injuries and stroke]

(17) 16 or 14

(18) Child/or Volition/or paediatric volitional question-

naire.mp. or Motivation/(1400753)

(19) Motivation/or dimensions of mastery questionnaire.mp.

(49586)

(20) 17 or 18 (1400754)

(21) 17and 19 (109)


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