Physical Therapy

Why Patients Don't Follow Their Home Exercise Programs

Physical therapy exercise equipment and tools arranged on a wooden floor, encouraging home exercise adherence for improved PT compliance.
Exercise adherence is critical for a successful recovery in physical therapy, but low participation is a massive challenge the industry is trying to overcome.

Physical therapists have limited time with patients during in-person sessions, so exercise adherence plays a pivotal role in the success of a treatment plan. But studies show that nonadherence to physical therapy can be as high as 70%, which poses a significant obstacle to patient outcomes.

Poor exercise adherence in physical therapy can result in negative patient outcomes and higher treatment costs. To keep their patients on the path to recovery, PTs must understand the barriers to physical therapy adherence and offer proactive solutions.

Why patients don’t follow their home exercise programs

Even though physical therapy compliance is critical to a successful recovery, many patients struggle to follow at-home exercise routines, which decreases their effectiveness. Understanding why patients struggle with physical therapy adherence can help PTs adjust their services to encourage patients to follow their HEPs over the long term.

Below are four common reasons why patients don’t keep up with at-home exercises.

Lack of resources

Even with a plan in place, patients who lack resources like time and equipment often struggle with exercise adherence. Even internal resources matter: a study of both patients and PTs found that a lack of willpower is one of the top barriers to physical activity.

Other common barriers to physical therapy adherence include:

  • Forgetting to exercise
  • Not having enough time to exercise
  • Not having anyone to exercise with
  • Lack of facilities or equipment
  • Lack of energy
  • Fear of injury

Pain during exercise

Sometimes, patients might be reluctant to follow their HEPs if their exercises worsen their pain. In fact, research shows that patients who experience pain while performing their exercises are less likely to adhere to their rehabilitation program.

Furthermore, a negative perception of physical therapy, e.g., PT results in pain, makes patients less likely to pursue treatment. To help their patients overcome these fears, PTs should teach them to identify normal pain that they can work through and abnormal pain that indicates improper form or another issue.

Little to no patient education

Patients who don’t know how to perform their at-home exercises are less likely to follow their treatment plans or even commit to physical therapy. Physical therapy clinics have reported that focusing on patient education results in improved exercise adherence, along with more realistic expectations and increased satisfaction among patients.

To provide effective patient education, PTs must clearly communicate their instructions for practicing the exercises and actively listen to their patients’ feedback, like their pain levels or their opinions on their treatment plan. For instance, during in-person sessions, make sure that your patient understands when you explain their treatment plan or demonstrate an exercise. If they seem disengaged, rephrase your explanation in simpler terms or try showing them a different exercise.

External locus of control

Patients who feel that their health is the result of factors outside of their control have lower rates of exercise adherence. When a patient believes they have no control of their health, they often feel anxiety or helplessness, which can worsen pain and discourage them from exercising.

Multiple studies have found that patients with high levels of internal locus of control experience lower pain intensity. An internal locus of control indicates that a patient trusts that they have effective coping methods to treat pain. In contrast, a patient with an external locus of control might feel like there is nothing they can do to improve their condition.

6 ways to improve physical therapy adherence

Physical therapy is used to treat injuries, pain, and other chronic conditions, so long-term physical therapy compliance is crucial for patients to maintain those benefits. Try these tips to help your patients improve their exercise adherence:

1. Create an exercise schedule with your patients

Many patients struggle to follow their HEPs because they can’t find time in their day to fit in their exercises. This can lead to a slower recovery than expected and discourage patients from sticking with physical therapy until they start to see results. To keep their patients on track, PTs can help create a structure that fits HEPs into their schedules.

When developing a treatment plan, talk to your patient about their day-to-day schedule to figure out when they can do their at-home exercises. Provide your patients with printed and digital versions of their custom exercise schedule, and encourage them to add their sessions to their planners or smartphone calendars, so they don’t forget.

Note: Exer Health offers patients an easy way to see which exercises they’re scheduled to do - and sends them reminders every day to complete their HEP!

Whether it’s due to work, school, or childcare, many patients have inflexible schedules that can make it hard to perform at-home exercises as prescribed. To accommodate them, you can suggest alternative exercise schedules that offer more flexibility. For example, four 15-minute sessions of exercise throughout the day will add up to a full 60-minute session. Empowering your patients to make their HEPs work for them can help them more easily comply with their treatment plan.

2. Increase your patients’ self-efficacy

Self-efficacy refers to a patient's belief in their capacity to execute on the behavior necessary to produce specific performance results - a self-belief in their own role in recovery. Learning how to identify low self-efficacy can help PTs develop realistic goals and recovery plans for their patients that encourage better physical therapy compliance. Over 70% of PTs surveyed reported that they assess their patients’ self-efficacy for at-home exercises before developing a treatment plan. However, these evaluations are usually limited to verbal discussions and patient observation.

In order to help patients build self-efficacy for better exercise adherence, you need a reliable baseline. PTs can use tools like the Self-Efficacy for Exercise (SEE) Scale and the Self-Efficacy for Home Exercise Programs Scale (SEHEPS) to more accurately evaluate their patients.

From there, PTs can take simple steps to increase their patients’ self-efficacy. For example, providing specific positive feedback on their exercises is much more encouraging than a simple nod of approval. Be sure to highlight your patient’s progress to show them how far they’ve come, so they feel confident in their ability to continue their exercises after their course of rehab.

3. Monitor your patients remotely to track their progress

Accountability is a powerful tool: when patients know that someone is checking on their progress, they are more likely to practice their HEPs as instructed. By using technology to remotely monitor patients, PTs can ensure that patients follow their treatment plans and offer proactive support to push patients toward greater exercise adherence.

Today it’s even easier for physical therapy clinics to add remote monitoring options for their patients. As of 2022, new remote therapeutic monitoring (RTM) codes enable physical therapists to remotely monitor and collect non-physiological data, such as therapy response and exercise adherence.

With remote monitoring, PTs can also make sure that patients perform their exercises correctly to reduce the risk of injury. Using artificial intelligence, Exer Health can measure patient performance without any extra equipment. The software takes range-of-motion measurements and can even count reps and provide in-exercise feedback to help patients improve their form. PTs can then review the data to evaluate patient progress, provide recommendations, and update their HEPs.

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4. Collaborate with your patients to make decisions and set goals

Recent research indicates that a strong therapeutic alliance seems to facilitate greater adherence to physical therapy and exercise in general. By working with their patients to set measurable, attainable home exercise goals, PTs can help patients develop internal motivation and gain momentum as they meet each goal.

For example, a mother of two is in physical therapy to rehabilitate her left leg, but between work and childcare, she doesn’t have a lot of time. She and her PT work together and agree that 30 minutes of exercise twice per week is a good treatment plan. To give the patient something to work toward, they set a goal for her to be able to take a 10-minute walk by the end of her second month of physical therapy.

Having greater autonomy in the physical therapy process empowers patients to feel confident in their ability to take control of their health. Share the responsibility of decision-making with your patients, so you can engage them in a collaborative, active approach to recovery.

5. Experiment with varying exercise frequencies and durations

Exercise adherence often drops as patients become bored or frustrated with their at-home exercises. One study found that a HEP should be limited to three prescribed exercises, as patient adherence drops when more exercises are required. PTs can offer alternative exercise protocols to keep patients engaged and improve physical therapy adherence.

In most situations, PTs can come up with multiple options for exercises or let patients decide how to incorporate their HEPs into their schedules. For instance, instead of a strict exercise plan, give your patients a choice between exercises that use weights, resistance bands, or body weight, depending on how they feel that day. You can also prescribe different durations, e.g., five sets of 10 reps for some exercises and three sets of 20 reps for others, to offer more variety to your patients.

6. Provide regular feedback, encouragement, and reassurance

Social support is a major component of a physical therapist’s responsibilities during treatment. Providing feedback to patients can help them overcome some of the barriers to exercise adherence, like low self-efficacy and motivation. For example, you can ask your patients to rate their pain levels from their exercises each week, so you can adjust their HEPs as needed.

By encouraging your patients to trust in the process, you can empower them to comply with their HEPs. Celebrate wins with your patients when they meet certain goals, so they know how well they’re doing and are motivated to keep going.

You should also reassure patients of the value of physical therapy adherence by sharing success stories and scientific research. For example, one study found that patients who performed their HEP between four and seven days per week had significantly lower pain levels than those who performed one to three days of HEP per week.

Inspire greater exercise adherence to improve patient outcomes

By consistently providing support, education, and flexibility in treatment plans, PTs can help their patients improve their exercise adherence to achieve long-term results and prevent future pain and injuries.

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