The Right Number of Exercises to Prescribe to Patients

Optimising Exercise Adherence in Physiotherapy, Osteopathy, Chiropractic and Sports Therapy

As therapists, one of the big challenges we have is encouraging patients to do their exercises. It is all well and good when a patient sees us in person, but what happens the rest of the time? Adherence to home exercise programs (HEPs) is a persistent challenge in musculoskeletal physiotherapy. Non-adherence can range from 50% to 70% in patients with chronic conditions ⁴, undermining clinical outcomes, increasing healthcare costs, and contributing to patient frustration and recurrence.

This article explores how simplifying exercise prescriptions, understanding patient barriers, and incorporating both behavioural and technological strategies can improve adherence. 

Why Adherence Matters

Patients who consistently follow their home programmes are more likely to regain function and reduce pain. However, when patients fail to adhere, it can mislead therapists into questioning the effectiveness of treatment and delay recovery. ¹ Poor adherence also burdens already strained healthcare systems.

Less is Best

I’m always surprised to see exercise plans by other therapists containing ten, fifteen or more exercises in the plans. This is simply a recipe to non-adherence. Unless your patient is a full-time athlete, or professional sportsperson, it really is not beneficial to prescribe more than 4 exercises in one plan. 

While a comprehensive exercise list might seem beneficial, it often overwhelms patients. Simpler is better. Clinical experience and behavioural science support the idea that fewer, focused exercises improve adherence by:

• Reducing cognitive load
• Improving recall and confidence
• Making programs easier to integrate into daily life

Ideally start with 1 to 3 exercises that directly relate to the patient's goals. Patients are more likely to comply when the program feels manageable and relevant. You can always review the exercises on the second session, and add more once your patient is comfortable with the first short batch. 

Keep it Simple, Silly

It is important to offer simple, straightforward, do-no-harm exercises unless you really know your patient well. Adopt the KISS principle. Keep it simple. Also, do no harm. Simple exercises are less likely to cause an injury or problem. The most basic exercises often work best, because patients “get them”, and understand them. If your exercise involves a hop, jump, and then single-leg romanian deadlift, it’s likely to lead to poor form and possibly even more pain. 

How many Exercises Should you Prescribe?

The correct answer is, it depends on the patient. However, we know from research that any more than 2 exercises per plan and adherence reduces. We think the sweet-spot is 3-4 exercises per plan. Don’t prescribe more than 5 per plan, and certainly not more than 10.

Bespoke, or Generic

Always bespoke. We design the right exercises, at the right time, for the right patient. Mrs Smith may be more comfortable doing a hip mobilisation sitting, and Mrs Jones may be more comfortable doing the same exercise lying. Knowing our patient is important. We should be prescribing exercises specifically for the needs, ability, skill and fitness level of that patient. 

Age is also a key factor in exercise prescription. As we age, our muscles atrophy, our co-ordination reduces, our balance reduces, and our flexibility reduces. A programme for an 80-year old is very different compared to a 60-year old, compared to a 40-year old, and so on. Again this shows the importance of good quality bespoke prescribing. 

Barriers to Adherence: Evidence-Based Insights

A systematic review ⁴ identifies multiple factors that influence adherence, including:

1. Low Self-Efficacy

Patients who doubt their ability to exercise successfully are more likely to disengage. ²

2. Pain During Exercise

Persistent or sharp pain often discourages patients, especially when they fear injury. Clear education on what sensations are expected versus harmful is critical. ¹

3. Psychological Barriers

Depression, anxiety, and helplessness are common in chronic pain populations and strongly linked with non-adherence. ⁴

4. Perceived Barriers

Time pressure, forgetfulness, and lack of routine are frequently cited. These are often modifiable with education and simple planning tools.

5. Poor Social Support

Patients without encouragement from family or peers may feel isolated or unmotivated.

6. Cultural and Contextual Barriers

Cultural and contextual barriers such as low awareness of physiotherapy, economic constraints, traditional health beliefs, family dependence (particularly affecting women), poor infrastructure, and communication gaps—can significantly impact adherence. ³ 

The Role of Technology

Digital health tools offer a promising way to bridge gaps in support and engagement. Argent et al. (2018) define connected health as technology-driven care that supports patients outside clinical settings through:

• Exercise demonstration videos
• Reminders and notifications
• Feedback via sensors or mobile apps
• Progress tracking and gamification

While research shows mixed evidence on whether apps significantly outperform other methods ¹, they may still enhance motivation, education, and accountability, especially for tech-literate patients.

Importantly, Argent and colleagues propose redefining adherence as:

“The extent to which an individual corresponds with the quantity and quality of exercise, as prescribed by their healthcare professional.”

This expanded view recognises that poor technique—even with regular practice—may undermine results.

Strategies to Improve Adherence

1. Patient Education

• Clarify pain vs. harm
• Use simple, relatable explanations
• Reinforce the purpose of each exercise

2. Motivational Interviewing

• Involve patients in setting goals
• Understand their values, fears, and lifestyle
• Build a shared plan they feel ownership over

3. Address Pain and Fear

• Introduce gentle, tolerable exercises first
• Use modalities like heat or TENS to improve comfort
• Celebrate small wins to build momentum

4. Visual Tools and Feedback

• Demonstrate exercises visually (videos or pictures)
• Encourage exercise logs or app-based tracking
• Review and adjust plans collaboratively

5. Cultural Adaptation

• Be aware of spiritual or traditional beliefs that may affect perceptions of treatment
• Communicate in the patient’s language whenever possible
• Involve families in the rehab process to improve support

In summary:

• Prescribe fewer, more relevant exercises
• Identify individual and cultural barriers early
• Use simple language and repeat key points
• Include social support networks where possible
• Stay open to tech tools but prioritise human connection

Improving adherence is not about prescribing more exercises, it’s about prescribing the right ones for that patient. 

By recognising both universal and culturally specific barriers to adherence, physiotherapists can create more effective, person-centred strategies. Simplifying the program, building strong communication, and embracing tools that meet patients where they are—whether that’s a smartphone app or a family-supported home routine—can lead to better outcomes and empowered, engaged patients.

References

1. Argent, R., Daly, A. and Caulfield, B., 2018. Patient involvement with home-based exercise programs: Can connected health interventions influence adherence? JMIR mHealth and uHealth, 6(3), p.e47. https://doi.org/10.2196/mhealth.8518
2. Bandura, A., 1997. Self-efficacy: The exercise of control. New York: Freeman.
3. Buddhadev, N., 2012. Physiotherapists’ perception of patient compliance to home exercises in chronic musculoskeletal physiotherapy. National Journal of Integrated Research in Medicine (NJIRM), 3(2), pp.162–165.
4. Jack, K., McLean, S.M., Moffett, J.K. and Gardiner, E., 2010. Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy, 15(3), pp.220–228. https://doi.org/10.1016/j.math.2009.12.004