Self-determination theory in physiotherapy practice: A rapid review of randomized controlled trials and systematic reviews

Self-determination theory in physiotherapy practice: A rapid review of randomized controlled trials and systematic reviews | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Self-determination theory in physiotherapy practice: A rapid review of randomized controlled trials and systematic reviews View ORCID Profile Jennifer O’Neil , View ORCID Profile Jacquie van Ierssel , Luc Pelletier doi: https://doi.org/10.1101/2025.03.05.25323439 Jennifer O’Neil 1 Faculty of Health Sciences, School of Rehabilitation Sciences, University of Ottawa , Ottawa, Canada 2 Bruyere Health Research Institute , Ottawa, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jennifer O’Neil For correspondence: joneil{at}uottawa.ca Jacquie van Ierssel 3 Children’s Hospital of Eastern Ontario , Ottawa, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jacquie van Ierssel Luc Pelletier 4 Faculty of Social Sciences, School of Psychology, University of Ottawa , Ottawa, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Background The self-determination theory (SDT) is a theory on motivation proposing to support needs of autonomy, competence, and relatedness to improves autonomous motivation, which leads to adherence and compliance. Little is known about how SDT-driven physiotherapy interventions are implemented. Purpose The objectives of this rapid review were to identify the type of physiotherapy contexts in which SDT is being used and describe how SDT-based physiotherapy interventions are being measured. Methods The Cochrane Rapid Review Methods was followed to synthesize evidence from systematic reviews (SR) and randomized controlled trials (RCTs) on the use of SDT-related research in physiotherapy. We conducted a search on four databases between 1990 and September 17 th , 2024. Two reviewers independently screened titles and abstracts, one reviewer completed the full-text screening while another screened all excluded full-text to ensure consensus. Findings were synthesized narratively following the review objectives. Results Of 184 identified SR or RCT, we included 8 RCTs (n=457) and 1 SR (n=712) targeting various health conditions for children and adults (i.e., cerebral palsy, adults with chronic condition). Physiotherapy interventions included strength and aerobic exercise, therapeutic modalities, yoga or tai chi, virtual therapy, coaching, and equine-assisted therapy. SDT techniques included communication training, autonomy supportive feedback, education and goal setting, provision of choices, and intrinsic motivation with the use of virtual reality, robotics, circus-themed games, music, and behaviour change strategies. A positive impact of SDT-driven physiotherapy interventions was seen for adherence, engagement, acceptance, physical activity, and intrinsic motivation. Conclusion Our rapid review suggests that SDT-driven physiotherapy is being used across a broad range of health conditions, using various physiotherapy and SDT principles derived from the theory. INTRODUCTION Despite the importance of motivation in determining patient adherence to interventions and impact on treatment outcomes, little attention has been given to how motivational theory is being applied in physiotherapy practice. For physiotherapy interventions to be effective, a person must adhere to the proposed plan and complete the exercises suggested. Adherence to physiotherapy home exercise and management strategies throughout the duration of physiotherapy sessions is integral to short-term recovery, while long-term adherence can often reduce the incidence of recurrence or re-injury. Several intervention parameters such as duration, mode of delivery, cost, as well as behavioural factors including self-efficacy may influence adherence 1 . Beyond the context of an intervention or behaviour of a client, a therapist’s behaviour may also have a significant impact on adherence. Precisely, interpersonal relationships, therapeutic relationship, shared-decision making are components that should be considered by a physiotherapist as they impact overall health outcome 2 . How a person behaves, in this case a physiotherapist, greatly influence motivation. Therapeutic relationships include person-centered care, interpersonal communication, and motivation strategies 2 all components well reflected in the self-determination theory of motivation. According to the self-determination theory (SDT), interpersonal interactions are an integral part of the human experience that can directly influence the quality of the motivation of a targeted person, in this case a patient. Self-Determination Theory SDT is a broad and comprehensive motivational theory developed by Deci and Ryan that has been widely used in psychology to inform interventions in the education, management, and health care sectors 3 , 4 . According to SDT, motivation varies not only in function of quantity but also quality 5 . That is, motivation is not a simple dichotomous construct where a person is more or less motivated to engage in a behavior, motivation can take different forms that vary according to their level of autonomy or self-determination. SDT typically distinguishes between autonomous and controlled motivations 5 , 6 . Autonomous motivation refers to behavior that could be intrinsically motivated (a behavior done because it is pleasurable, that is an end in itself) and to behavior that could be extrinsically motivated (i.e., a mean to an end) but still self-determined. SDT refers to two types of self-determined extrinsic motivation, integrated regulation (where a behavior is further internalized by taking in consideration other dimensions of the self that are considered important) and identified regulation (where an internalized behavior is done by choice because it is considered important). Controlled motivation refers to behavior that are regulated by internal factors (like internal obligations, shame, guilt) that have been poorly internalized or external factors (like incentives, constraints, pressures from others). The more a behavior is autonomously regulated (or self-determined), as opposed to controlled (or non self-determined), it is likely to be integrated to a lifestyle and to lead to positive outcomes such as well-being 5 , 6 . SDT proposes that for a person to be fully autonomous motivated and engaged in an activity, therapists should support the development of autonomous motivation from a self-determination stance by fulfilling basic psychological needs of: (1) autonomy (i.e., the need for individuals to act in line with their own interests and values), (2) competence (i.e., opportunities for increasingly challenging activities and developing greater levels of mastery), and (3) relatedness (i.e., needing a caring, supportive social network with strong interpersonal connections) 4 , 7 . These three needs are said to be innate and universal across cultures. Need-supportive behaviours (i.e., supporting one’s autonomy, competence, and need for relatedness) promote need-supportive environments; while need-thwarting behaviours (autonomy thwarting/controlling, competence thwarting, and relatedness thwarting) lead to need-thwarting environments 7 . According to SDT, if an individual’s context supports their basic psychological needs, their needs are more likely to be satisfied, which leads to autonomous motivation for a given activity. This allows them to engage in that activity out of interest or curiosity, or because it is in line with their goals and objectives 7 . Alternatively, if an individual’s basic psychological needs are not met, they are more likely to be dissatisfied and engage in a behaviour for controlled reasons, such as to comply with or please someone else, or to avoid feeling guilt or shame. When individual engage in a behavior for controlled reasons, they are less likely to learn, to find the experience satisfying, and, in turn, to persist or maintain an activity. Since physiotherapy is often dependent on clients’ motivation and capacity for undergoing significant health behaviour change, a comprehensive review of how SDT improve patients’ active involvement with physiotherapy and facilitate health behavior change was necessary. SDT in physiotherapy Autonomous motivation has been identified as an important contributor to physical activity adoption and intervention adherence 8 , 9 and can enhance a patient’s active participation within medical encounters 10 . In terms of healthcare service delivery, needs-supporting relationships are as important when delivering services in-person as when using telehealth 4 , 7 . Behaviours change techniques based on supporting basic psychological needs (autonomy, competence, relatedness) may present as goal setting, shared decision making, or occupational coaching in rehabilitation delivery. However, in rehabilitation-specific professions, the use of SDT is still in its infancy. In speech language pathology, a scoping review looking at aphasia and motivation identified a potential positive influence in clinical research for aphasia 11 . In physiotherapy, the perception of a physiotherapist’s behaviour was shown to be important in the delivery of a telerehabilitation intervention 12 . Autonomy, competence, and relatedness-supporting strategies, including, but not limited to, sharing of achievements, encouragement, and exchange of information, were systematically highlighted to be critical in peer support pain management rehabilitation groups 13 . Although the influence of SDT has been indirectly studied in areas related to physical activity adherence, pain reduction, return to sport, and aphasia interventions, a gap still exist in understanding its specific use in physiotherapy intervention and how SDT is being delivered in that specific context 9 , 14 . According to the Canadian Physiotherapy Association, physiotherapy is “the assessment, diagnosis, and treatment of the human body, its diseases, disorders and conditions associated with physical function, and acute or chronic injury or pain. It includes the prevention of illness or injury and promotion and education on health and wellness with a focus on optimal movement and function” 15 . Since prior physiotherapy research identified possible impact of components of self-determination theory implementation in a physiotherapy intervention 16 , we chose to document the precise use of this specific theory on the physiotherapy profession to facilitate reproducibility in a physiotherapy clinical context. In doing so, our aim is to examine the specific components of physiotherapy intervention that could be related to the satisfaction of the three basic needs proposed by SDT, that the behavior targeted by the intervention shows signs of internalization, and that this behavior is associated to the positive outcomes typically pursued by an effective physiotherapy intervention. More specifically, the primary objective of this rapid review was to identify the physiotherapy contexts in which SDT is currently being used to determine whether using SDT principles within physiotherapy practice is effective at improving physiotherapy intervention adherence, facilitating education, and self-management. Our secondary objective was to describe the populations receiving SDT-based physiotherapy and how SDT-based physiotherapy interventions are being measured. Identifying this information will lead to the development of more effective SDT-driven physiotherapy interventions. METHODS Rapid reviews improve accessibility and clarity of research evidence 17 , 18 . Adhering to Cochrane methodology for rapid review 19 , we examined how SDT approaches are being used within physiotherapy services to inform future program development. Based on high-quality evidence (i.e., RCTs and SRs), we wanted to identify the clinical application of theory to the population being targeted by this type of intervention and the methods of delivery in a physiotherapy context. We registered our protocol in the Open Science Framework repository before starting data extraction ( https://doi.org/10.17605/OSF.IO/FP8JM ). Specifics of the Cochrane methodology for rapid review are described in each methodology section. Search strategy The search strategy was piloted in one database (i.e., MEDLINE) using Boolean logic “and/or” to combine specific MeSH terminology including study design (i.e., randomized controlled trial, systematic review), SDT (i.e., autonomy, determination, satisfaction, psychological needs, autonomous motivation), and physiotherapy (i.e., physical therapy, physiotherapy modalities, physical rehabilitation) (table in appendix). We subsequently expanded the search to include needs satisfaction in Cochrane Library (OVID), PsycInfo, and Embase databases between 1990 and January 2023. We updated the search in September 2024. We then hand searched the references of included full texts. Study selection We screened citations using the review management software Covidence TM. Two reviewers (JO, JvI) piloted a standardized title and abstract form for calibration before screening all articles by using the same 30 studies found in the initial MEDLINE search. As per Cochrane rapid review methodology, after duplicates were removed, two reviewers independently screened 50% of the titles and abstracts based on the following inclusion and exclusion criteria: systematic reviews and RCTs published in English and studies targeting physiotherapy services or exercise interventions based on SDT. Exclusion criteria will be incomplete studies, poster or protocols. In this review, the person who delivered the exercise program or physical activity was considered. Precisely, to be included, for an exercise program to be considered a physiotherapy intervention, the intervention needed to be delivered by a physiotherapist. Exercise or physical activity interventions were excluded when they were delivered by other health professionals or when the provider was not specified. Once consensus was achieved, one reviewer (JO) completed the review of all titles and abstracts. Our inclusion criteria were SRs and RCTs published in English between 1990-2024, targeting physiotherapy services (i.e., evaluation, interventions, service delivery) or exercise interventions provided by a physiotherapist, and used SDT in the development of the interventions or assessments. Protocols and observational studies were excluded. Using the same process as above, we screened 10 full-text studies to pilot the full-text reviewing form. One reviewer (JO) completed the screening of all full texts while another reviewer (JvI) independently screened all excluded full text. Conflicts were resolved by discussion between reviewers until consensus was reached. Data extraction and synthesis Data extraction was completed using a standardized form ( appendix B ) to extract how physiotherapy interventions and SDT techniques (i.e., communication, education, training program, behaviours, were delivered (i.e., in-person, telerehabilitation, hybrid), types of physiotherapy outcomes (i.e., adherence, effectiveness, health-equity) and SDT psychological needs(i.e., autonomy, competence, relatedness motivation, adherence, effectiveness, health-equity) being targeted, and the population and types of health conditions being investigated. The behavioural change technique classification of the data was informed by Teixeira et al. (2020) 20 . Data was extracted by one reviewer (initials here-anonymous) and reviewed by a second (initials here-anonymous). Two independent reviewers assessed Risk of Bias using the ROB2 tool 21 for RCTs and the AMSTAR2 tool 22 , 23 . We followed the PRISMA reporting guidelines 23 . Findings were analyzed narratively following the review objectives to identify similarities and differences between studies and synthesized descriptively in tables 24 . RESULTS Included studies Of 184 citations identified, we removed 58 duplicates, screened 126 titles and abstracts, reviewed 54 full-texts, and included 8 RCTs (n= 445 participants) and 1 SR (n=712 participants) ( table 1 ). Interrater reliability for titles and abstracts selection was strong (k 0.88). The 9 studies retained in this review represented 1157 participants with an average age ranging from 3 to 77 years old. Only one systematic review targeted people under the age of 18 25 . The terminology for sex and gender was often interchanged, leaving no explicit reporting of gender in any of the studies. The four most recent RCTs 26 – 29 published between 2022 and 2024 reported more health equity indicators (i.e., socio-economic factors, employment, level of education, gender, race, and culture) compared to the four published earlier. View this table: View inline View popup Table 1. Physiotherapy interventions, intervention delivery, and outcomes. Abbreviations: HIV , human immunodeficiency virus; RCT , randomized controlled trial; SDT , self-determination theory. Risk of Bias Overall, two of the RCTs were rated as low ROB while 6 RCTs were rated as having some concerns ( figure 2 ). Concerns were mostly related to the randomization process and missing data. The SR by was assessed as high quality using the AMSTAR 2 tool 22 , however, the lack of protocol registration could introduce bias. Download figure Open in new tab Figure 1. Prisma Chart illustrating the identification, screening, and inclusion process 23 . Download figure Open in new tab Figure 2. Reporting on Risk of Bias (ROB) of the RCTs assessed by the ROB2 tool 30 . Physiotherapy and SDT interventions Patient populations included adults living with specific orthopedic conditions (including chronic low back pain, those requiring hip and knee replacements, and sedentary women) and adults and children with specific neurological conditions (including HIV, Huntington disease, and children with motor development conditions such as cerebral palsy, brachial plexus injuries, and gait development impairments, and autism spectrum disorder). One RCT targeted adults with coronary heart disorder and one was conducted with healthy students ( table 1 ). Several types of physiotherapy interventions for children and adults were included such as traditional strength and aerobic exercise programs 26 – 28 , 31 – 34 , virtual reality therapy 25 , 35 , and equine-assisted therapy 25 . Diverse settings included outpatient hospitals 32 , 34 , hybrid interventions 26 , home and community 25 – 29 , 34 , 36 and research laboratories 35 ( table 1 ). The SR by Meyens et al. focused on delivery of different motivational techniques including the use of virtual reality, robotics, circus-themed games in a goal-based approach to improve intrinsic motivation in children with developmental disorders 25 . Five out of eight RCTs used multifactorial motivational strategies including goal setting, education on physical activity, exploration of barriers and facilitators, problem solving, adherence, social interaction, and self-monitoring 26 – 29 , 34 . Another RCT 35 conducted with healthy students in laboratory environments used virtual reality to compare autonomy-supportive and autonomy-controlling tasks. In contrast, Murray et al. (2015) 32 used hybrid behavioural change techniques and methods of delivery, including video recording, vignettes, active role-playing, and group discussions to enhance the physiotherapist’s abilities to support their patient’s needs. Novel combinations of in-person, group videoconference, and phone applications 27 , the benefit of music and phone calls 26 , and phone interviewing and text-messages 29 were also documented. While other RCTs relied on a combination of simple methods, including in-person and phone calls 28 , 33 , Aunger et al. (2020) only included in-home, in-person motivational strategies 34 . Outcomes and outcome measures RCTs measured outcomes related to physical activity and function, behaviour changes, mental health outcomes, quality of life, and a combination of these ( table 3 ). Specific to physical activity level, seven RCTs 26 – 29 , 33 – 35 used a variety of outcome measures, including self-reported questionnaires, clinical assessment, and objective kinematic measures. Five RCTs 26 – 29 , 34 used wearable technology to capture step count and overall daily physical activity in real-world context. Other physical outcomes and outcome measures included strength measured by dynamometer 33 , function measured by daily repetitions of sit-to-stand 34 , and overall disability 29 . View this table: View inline View popup Table 2. Motivation Behaviour Change Techniques (MBCT), SDT intervention and delivery and outcomes. Abbreviations: MBCT - Motivation Behaviour Change Techniques, SDT – Self-determination theory. Note: The number beside MBCT refers to the Classification of Motivation and Behavior Change Techniques label/taxonomy. View this table: View inline View popup Table 3. Outcomes measures used in physical or behaviour change domains. Abbreviations: EuroQol EQ-5D-5L , European Quality of Life – 5 Dimensions, 5 Levels; ISWT , Incremental Shuttle Walk Test; PA , physical activity; WHO , World Health Organization. Outcomes related to needs-supportive behaviour changes and mental health were mostly measured using questionnaires and validated scales. Motivation and engagement were measured in the SR (Meyns et al., 2018) and six RCTs 26 , 27 , 29 , 33 – 35 . The most frequently used measure for motivation and engagement was the Behavioral Regulation in Exercise Questionnaire (3 out 9 studies). Changes in mood and mental health were measured in three RCTs 28 , 29 , 33 with the Beck Depression Inventory, and the Positive and Negative Affect Schedule. Finally, quality of life was measured in three RCTs 28 , 29 , 33 using three different measures, the Short-Form Health Survey-36, the Short-Form Health Survey-12, and the EuroQuol EQ-5D-5L survey. Adherence or attendance was measured differently across studies, including reporting of adherence to action plans in a booklet (comprised of six goals and three environmental modifications) 34 and percentage of sessions attended 27 , 28 . Intervention fidelity was measured in 3 RCTs by rating the delivery of skills 34 , self-reporting checklist from physiotherapists 28 , and use of wearable sensors 27 , 28 . Two RCTs measured safety, and one RCT measured satisfaction and acceptability. Efficacy of physiotherapy services combined with SDT interventions One RCT reported a significant increase in physiotherapists’ needs-supportive behaviours with SDT interventions measured by the Health Care Climate Questionnaire (intervention arm [mean ±SD] = 4.6±0.85; control arm [mean ±SD] = 2.78 ±0.72) 38 . In terms of intervention feasibility and acceptability, one RCT reported that combining in-person physiotherapy services with motivational interviewing, emotional support, education, and problem-solving is feasible and may have an impact on sedentariness in older adults awaiting hip and knee arthroplasty 34 . Another RCT demonstrated that combining online physiotherapy program with health coaching emails and text message was feasible and an acceptable for women over 50 years old 29 . A third RCT showed that combining moderate-vigorous exercise 3–5 times per week with 18 physical activity coaching sessions may have a positive impact on walking endurance and self-reported physical activity in people living with Huntington’s disease 28 . Findings also suggest that combined physiotherapy interventions with SDT-based interventions could significantly improve physical function such as gait speed in people with HIV 33 , exercise capacity and exercise efficacy in people with coronary heart disease 26 , and self-reported physical activity in adults with autism spectrum disorder 27 . DISCUSSION In this rapid review, we describe the use of SDT techniques combined with physiotherapy interventions, how they are measured, and their reported outcomes based on high quality evidence. Our findings also provide some insight on how physiotherapy interventions combined with SDT techniques are currently being delivered (e.g., aerobic exercise, virtual reality, problem-solving tools, reframing), how are these interventions currently being assessed (e.g., physical activity levels, motivation, mood and behaviour), and for whom they have been designed. Overall, our findings suggest that SDT techniques combined directly with specific physiotherapy interventions is feasible for people with a variety of health conditions, including children with neurodevelopmental disorders such as cerebral palsy, adults with certain neurological conditions including HIV and Huntington’s disease, adults waiting hip or knee replacement or who are sedentary, and adults with cardiovascular conditions. Studies on the impact of physiotherapy and SDT interventions developed for adults and older adults with neurological conditions such as stroke, traumatic brain injury, spinal cord injury, and neuroinflammatory conditions are still lacking 39 , 40 . Since research shows that personalization and tailoring of physiotherapy interventions based on the SDT framework positively impact motivation in people who have experienced a stroke 41 , however the current literature does not report enough details on the types of tailoring or motivational strategies to enable clinical recommendations or replication 42 . It is necessary to understand the specific motivation and behaviour change techniques used within specific contexts and with specific populations to tailor care. This review also showed that supporting competence of physiotherapist using SDT techniques may indirectly influence communication skills of physiotherapists, which may improve therapeutic relationships between clinicians and patients 12 . Furthermore, results from cohort studies included in Meyns et al. suggest that the use of virtual reality as well as meaningful partnerships may improve active engagement within a physiotherapy and effectiveness of the intervention 43 – 46 . The impacts of combining SDT specific behaviour change techniques within a physiotherapy framework may have an impact on both, clinicians and patients. Consistent with findings from a meta-analysis by McGrance et al., motivational SDT interventions included in this rapid intervention primarily improved adherence, exercise behaviour, and levels of physical activity 47 . From a motivational and behaviour change perspective, results from this rapid review also showed positive outcomes related to clinicians’ needs supportive behaviours as well as patients’ self-efficacy and acceptance. The challenges now lie with knowledge of such complex interventions and how to implement them clinically. Approaches such as co-creation of interventions or shared-decision activities might be beneficial 10 . Training of future physiotherapist on the implementation of behaviour change within a clinical context is critical. Furthermore, our results suggest that is feasible for physiotherapy interventions combined with behaviour changes and SDT techniques to be delivered in various modes. It demonstrates the potential of alternative physiotherapy delivery options (i.e., in-person, telerehabilitation, robot-assisted, hybrid) and SDT techniques delivery options (e.g., in-person, telerehabilitation, virtual reality, phone sessions, text-messages). When comparing in-person and telerehabilitation in physiotherapy, emerging evidence shows similar results for satisfaction, adherence, and effectiveness for certain conditions 48 – 50 . Our findings showcase the acceptability and effectiveness of diverse physiotherapy care delivery. Similarly, the delivery of interventions, both physiotherapy and SDT, was reported to be feasible and accepted in various settings (hospital, virtual reality, research laboratory, vignettes). Further high-quality research is needed to explore how physiotherapy and behaviour change techniques can be integrated in complex interventions, to identify if the method of delivery has an impact on outcome, and how the method of delivery may influence the design of complex telerehabilitation interventions. Interesting findings around outcome measures is highlighted. Our rapid review demonstrated a lack of standardized outcome measures related to autonomous motivation, communication and interpersonal behaviours and their validation for physiotherapy interventions. This is an important clinical and research gap since autonomous motivation has been demonstrated to have an impact on health behaviour 51 . Assessment tools objectively measuring the impact of SDT combined with physiotherapy interventions may be necessary to demonstrate the effectiveness of SDT-driven physiotherapy. Reliance of self-report may create limitation in the assessment of effectiveness of SDT-driven physiotherapy. Rouse et al. provide an example of a validated tool measuring the interpersonal support in physical activity consultation 52 . Others have proposed self-determination specific questionnaires such as the Health Care Climate Questionnaire, the Perceived Competence Scale, and Treatment Self-Regulation Questionnaire 53 . Without access to or use of validated tools designed to measure if and how a motivation-based intervention may influence physiotherapy interventions, the inclusion of SDT interventions within physiotherapy may be limited. This review could influence the development or clinical use of new self-determination-based outcome measures that are simple to use in all geographical context and languages. Finally, demographic findings demonstrate gaps in explicit reporting of health equity indicators. Reporting of health equity indicators could not only improve transparency in reporting but provide critical information on the context in which the person is living 54 for whom a combined physiotherapy and SDT intervention would be beneficial. Results from our updated search demonstrates a positive trend in the reporting of key socio-demographic indicators. Future work should document in detail how health equity indicators are considered and how SDT interventions and supporting basic psychological needs could influence the effectiveness of an intervention from a sex and gender-based analysis, a cost-effectiveness analysis, or an accessibility analysis. Practical Implications Supporting basic psychological needs combined with physiotherapy interventions may have a positive impact on a clinician’s therapeutic approach as well as certain patient health outcomes, adherence to intervention, and the development of effective therapeutic relationships. Behaviour change techniques should be systematically included as part of the physiotherapy curriculum as well as a continuing education topic for current physiotherapists, focusing on hands-on implementation rather than theoretical ideas. Combining physiotherapy interventions and SDT techniques is feasible and acceptable for various health conditions within various health care settings. It is therefore important to document how these interventions have been implemented and integrated into new interventions or clinical practice to facilitate implementation. Combining physiotherapy interventions (i.e.., moderate to high intensity resistance training, aerobic training, constraint–induced movement therapy) and SDT techniques (virtual reality, person-centered coaching sessions, music) can improve adherence to intervention, physical activity levels, and intrinsic motivation. Physiotherapists should strive to combine these interventions tools to improve self-efficacy and consequently efficacy of interventions. Limitations We acknowledge that the exclusion of other motivational theories may limit the generalization of our results. Future reviews may want to include other motivational theories, compare their impact, and synthesize their differences. It is critical to consider some limitations encountered during the screening and selection process of the studies. Unfortunately, the type of provider delivering the physical activity, physiotherapy of exercise program was often not reported. Since “physiotherapy or physiotherapist” was a specific inclusion criterion, many studies discussing ‘health or rehabilitation’ interventions were excluded. There is a need to report who is providing the intervention in studies to enable replication as well as personalize training around SDT for each health profession. The SDT interventions and behavioural change techniques presented in this review were not always reported based on the target behaviour change (competence, autonomy, relatedness support). Similar to documenting the details of physiotherapy interventions, precise reporting using validated measures of autonomous motivation or precise reporting of how the basic psychological needs of competence, autonomy, and relatedness may be supported or thwarted in physiotherapy, could impact clinical practice and effectiveness of physiotherapy interventions 3 . Furthermore, due to the lack of consistency in outcome measures, a meta-analysis of results was not possible for this rapid review. It is therefore essential to consider using consistent validated measures, such as validated measures of physiotherapist’s needs-supportive and needs-thwarting interpersonal behaviours, and autonomous and controlled motivation for engaging in physiotherapy, when conducting effectiveness trials to allow for the development of robust clinical guidelines on SDT driven physiotherapy interventions. To mitigate this limitation, we narratively synthesized the results from each included study which allowed us to provide preliminary information on feasibility and effectiveness. CONCLUSION With a growing push towards the use of person-centered approaches, goal setting, and shared decision making in physiotherapy, results from this rapid review demonstrate how SDT-designed physiotherapy intervention can be clinically implemented by identifying various types of SDT and physiotherapy interventions across various contexts. This review also identified key SDT interventions such as problem solving, problem monitoring, and goal setting which may, when combined with evidence-based physiotherapy interventions, improve the effectiveness of interventions. However, given the paucity of evidence of SDT interventions within physiotherapy, further research around implementation and delivery is needed before robust conclusions can be drawn as to the effectiveness on patient outcomes. This information may facilitate clinical implementation of SDT within physiotherapy, provide guidelines for the initiation and maintenance of health behaviours and specific adherence-interventions, as well as inform future training of physiotherapists. Data Availability All data produced in the present study are available upon reasonable request to the authors Acknowledgements NIL Appendix A View this table: View inline View popup Appendix B Data extraction form View this table: View inline View popup Download powerpoint Acknowledgements and Conflict of interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare that they have no financial conflict of interest with the content of this article. Footnotes social{at}uottawa.ca , jminnes{at}cheo.on.ca Ethics approval: This was a systematic rapid review; therefore, no ethics approval was necessary. 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Share Self-determination theory in physiotherapy practice: A rapid review of randomized controlled trials and systematic reviews Jennifer O’Neil , Jacquie van Ierssel , Luc Pelletier medRxiv 2025.03.05.25323439; doi: https://doi.org/10.1101/2025.03.05.25323439 Share This Article: Copy Citation Tools Self-determination theory in physiotherapy practice: A rapid review of randomized controlled trials and systematic reviews Jennifer O’Neil , Jacquie van Ierssel , Luc Pelletier medRxiv 2025.03.05.25323439; doi: https://doi.org/10.1101/2025.03.05.25323439 Citation Manager Formats BibTeX Bookends EasyBib EndNote (tagged) EndNote 8 (xml) Medlars Mendeley Papers RefWorks Tagged Ref Manager RIS Zotero Tweet Widget Facebook Like Google Plus One Subject Area Rehabilitation Medicine and Physical Therapy Subject Areas All Articles Addiction Medicine (568) Allergy and Immunology (863) Anesthesia (300) Cardiovascular Medicine (4436) Dentistry and Oral Medicine (444) Dermatology (382) Emergency Medicine (608) Endocrinology (including Diabetes Mellitus and Metabolic Disease) (1509) Epidemiology (15229) Forensic Medicine (30) Gastroenterology (1124) Genetic and Genomic Medicine (6600) Geriatric Medicine (668) Health Economics (997) Health Informatics (4538) Health Policy (1368) Health Systems and Quality Improvement (1613) Hematology (542) HIV/AIDS (1264) Infectious Diseases (except HIV/AIDS) (15916) Intensive Care and Critical Care Medicine (1103) Medical Education (623) Medical Ethics (146) Nephrology (667) Neurology (6599) Nursing (346) Nutrition (998) Obstetrics and Gynecology (1144) Occupational and Environmental Health (957) Oncology (3333) Ophthalmology (974) Orthopedics (369) Otolaryngology (420) Pain Medicine (436) Palliative Medicine (130) Pathology (663) Pediatrics (1693) Pharmacology and Therapeutics (691) Primary Care Research (711) Psychiatry and Clinical Psychology (5447) Public and Global Health (9232) Radiology and Imaging (2198) Rehabilitation Medicine and Physical Therapy (1370) Respiratory Medicine (1196) Rheumatology (593) Sexual and Reproductive Health (712) Sports Medicine (530) Surgery (712) Toxicology (99) Transplantation (289) Urology (265) (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'a01038a61f2506f3',t:'MTc3OTY2NjgyMg=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();