Rehabilitation after stroke has been described as a process in which the patient and the healthcare system, through interaction and negotiation, try to reach agreement about activities to be emphasised and goals to be pursued.Involvement and empowerment of the patient are implicit in, and integral to, this process. Participation in setting goals seems to have a positive impact on patients' motivation, and there is now consensus among professionals in stroke rehabilitation that the patient's degree of motivation will influence the outcome of an intervention. Consequently, an important element of any proposed intervention should be an assessment of what the patient is motivated to achieve as well as the promotion of a high level of motivation.

The World Health Organization's International Classification of Functioning and Disability defines motivation as a global mental functiona conscious or unconscious drivethat produces the incentive to act. Essential components of the classification are those contextual conditions, such as personal and environmental factors, that interact with body function, activity, and participation. Thus, motivation may be influenced by both personal factors (such as age, gender, personality, educational and social background, experience, coping capacity, health status, and lifestyle) and environmental factors, which together shape the physical, social, and attitudinal context for rehabilitation.

Clinically it is often assumed that "low motivation" in patients with stroke is a symptom of depression. Can low motivation be attributed to organic damage resulting from the destruction of brain tissue, to reactions to a changed life situation after a stroke, to personality traits, or to environmental demands and expectations? There are no straightforward, indisputable answers to these questions. Nevertheless, most of the emotional disturbance in patients with stroke is probably not the result of specific brain damage. Recently, researchers have begun to ask what characteristics enable patients to play an active part in managing their illness and recovery. Antonovsky has called this process "salutogenic orientation."

The impact of environmental factorsfor example, the effect of being in hospitalon the behaviour of patients with stroke, including their initiative and autonomy, is not well understood. Yet the low level of activity initiated by stroke patients when they are in hospital,and the disempowering nature of their role as patients, suggest that we should pay close attention to environmental factors in rehabilitation.

In our study of the influence of the environment in recovery we observed clear differences in both patients' and therapists' behaviour when rehabilitation sessions in patients' homes were compared with those in hospital. Patients undergoing rehabilitation at home took the initiative and expressed their goals more often than those undergoing hospital rehabilitation. Rehabilitation at home thus seemed to empower patients.

In a recent study in the BMJ Maclean et al explored the attitudes and beliefs of patients with stroke identified by professionals as having high or low motivation for rehabilitation. The patients reported how their attitude towards rehabilitation was influenced by a range of environmental factors, such as the manner in which healthcare professionals communicated information; overprotection by family members and nurses; comparisons with other patients' performance; and the unstimulating hospital milieu. Patients with high and low motivation placed different emphases on how environmental factors influenced their attitude towards rehabilitationa finding that highlights the need for further research into the way in which personal and environmental factors affect motivation.

A Swedish study of rehabilitation after a stroke reported that patients on geriatric wards did not participate in setting the goals of their rehabilitation. In our own randomised controlled study of care after stroke, which compared early supported discharge and continued rehabilitation at home with routine hospital based rehabilitation, significantly more patients in the home rehabilitation group reported that they were actively involved in planning their rehabilitation programme. Being at home enabled them to assume responsibility for, and exert their influence on, their own rehabilitation, which they carried out in partnership with their therapists.12 In contrast, the hospital environment, with its enforcement of the role of "patient," probably does not promote this type of initiative in people who have had a stroke.

The challenge therefore is to develop strategies that encourage patients to adopt the same autonomy and control as they do at home in other settings where rehabilitation services are provided. Healthcare providers need to find the best ways of supporting stroke patients so that they identify their own problems and express their goals. Furthermore, patients should be given the opportunity to take part in both the planning and evaluation of their rehabilitation. Contextual barriers to patient involvement, often inherent in the design of the rehabilitation process and in decisions concerning itin particular in the hospital environmentneed to be identified and removed. Otherwise we are faced with the uncomfortable knowledge that the setting for rehabilitation might itself be undermining the effectiveness of that rehabilitation.