The Importance of Voluntary Behavior in Rehabilitation Treatment and Outcomes

Published:September 26, 2018DOI:


      Most rehabilitation treatments are volitional in nature, meaning that they require the patient’s active engagement and effort. Volitional treatments are particularly challenging to define in a standardized fashion, because the clinician is not in complete control of the patient’s role in enacting these treatments. Current recommendations for describing treatments in research reports fail to distinguish between 2 fundamentally different aspects of treatment design: the selection of treatment ingredients to produce the desired functional change and the selection of ingredients that will ensure the patient’s volitional performance. The Rehabilitation Treatment Specification System (RTSS) is a conceptual scheme for standardizing the way that rehabilitation treatments are defined by all disciplines across all areas of rehabilitation. The RTSS highlights the importance of volitional behavior in many treatment areas and provides specific guidance for how volitional treatments should be specified. In doing so, it suggests important crosscutting research questions about the nature of volitional behavior, factors that make it more or less likely to occur, and ingredients that are most effective in ensuring that patients perform desired treatment activities.


      List of abbreviations:

      COM-B (Capability, Opportunity, Motivation and Behavior), RTSS (Rehabilitation Treatment Specification System), VR (virtual reality)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lima-Dellamora E.D.
        • Osorio-de-Castro C.G.
        • Madruga L.G.
        • Azeredo T.B.
        Use of pharmacy records to measure treatment adherence: a critical review of the literature.
        Cad Saude Publica. 2017; 33e00136216
        • Náfrádi L.
        • Nakamoto K.
        • Schulz P.J.
        Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence.
        PLoS One. 2017; 12e0186458
        • van Heuckelum M.
        • van den Ende C.H.
        • Houterman A.E.
        • Heemskerk C.P.
        • van Dulmen S.
        • van den Bemt B.J.
        The effect of electronic monitoring feedback on medication adherence and clinical outcomes: a systematic review.
        PLoS One. 2017; 12e0185453
        • Allemann S.S.
        • Nieuwlaat R.
        • Navarro T.
        • Haynes B.
        • Hersberger K.E.
        • Arnet I.
        Congruence between patient characteristics and interventions may partly explain medication adherence intervention effectiveness: an analysis of 190 randomized controlled trials from a Cochrane systematic review.
        J Clin Epidemiol. 2017; 91: 70-79
        • Witry M.J.
        • LaFever M.
        • Gu X.
        A narrative review of medication adherence educational interventions for health professions students.
        Am J Pharm Educ. 2017; 81: 95
        • Hart T.
        • Dijkers M.P.
        • Whyte J.
        • et al.
        A theory-driven system for the specification of rehabilitation treatments.
        Arch Phys Med Rehab. 2018;
        • Van Stan J.
        • Dijkers M.P.
        • Whyte J.
        • et al.
        The Rehabilitation Treatment Specification System: implications for improvements in research design, reporting, and synthesis.
        Arch Phys Med Rehab. 2018;
        • Zanca J.
        • Hart T.
        • Whyte J.
        • et al.
        Advancing rehabilitation practice through improved specification of interventions.
        Arch Phys Med Rehab. 2018;
        • Strasser D.C.
        • Burridge A.B.
        • Falconer J.A.
        • Herrin J.
        • Uomoto J.
        Measuring team process for quality improvement.
        Top Stroke Rehabil. 2010; 17: 282-293
        • Strasser D.C.
        • Falconer J.A.
        • Stevens A.B.
        • et al.
        Team training and stroke rehabilitation outcomes: a cluster randomized trial.
        Arch Phys Med Rehab. 2008; 89: 10-15
        • Hoffmann T.C.
        • Glasziou P.P.
        • Boutron I.
        • et al.
        Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide.
        BMJ. 2014; 7: g1687
      1. Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P, CONSORT NPT Group. CONSORT Statement for Randomized Trials of Nonpharmacologic Treatments: A 2017 Update and a CONSORT Extension for Nonpharmacologic Trial Abstracts. Ann Intern Med. 2017;167:40-7.

        • ICHI
        ICHI Beta 2017. International Classification of Health Interventions.
        (Available at:) (Accessed February 1, 2018)
        • Slade S.C.
        • Dionnec C.E.
        • Underwood M.
        • Buchbinder R.
        Consensus on exercise reporting template (CERT): explanation and elaboration statement.
        Br J Sports Med. 2016; 50: 1428-1437
        • Cohn S.
        • Lynch R.
        Falling into a routine: from habits to situated practices.
        Sociol Health Ill. 2017; 39: 1398-1411
        • Johnson B.T.
        • Acabchuk R.L.
        What are the keys to a longer, happier life? Answers from five decades of health psychology research.
        Soc Sci Med. 2018; 196: 218-226
        • Michie S.
        • van Stralen M.M.
        • West R.
        The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
        Implement Sci. 2011; 23: 42