Why patients skip home exercises: what the adherence research says

Every therapist knows the moment. You ask how the home program went, and the answer comes a little too quickly: "Pretty good, mostly." Then the hand tells a different story.

Ohio State Wexner Medical Center commissioned a survey of 1,006 Americans about at-home physical therapy. As Medical Economics reported in February 2026, 76% said they did not complete all of their assigned home exercises. The reasons they gave:

• forgot, or had no reminders (40%)
• not enough time, or schedule conflicts (33%)
• the exercises were boring or repetitive (22%)
• no accountability between visits (15%)

Two cautions before leaning on those numbers. This was a commissioned consumer survey, not a peer-reviewed study, and the article does not name the polling firm or the fieldwork dates. And "did not complete all" is not the same as "did none": the figure lumps together the patient who missed one session with the patient who never started. Still, the reasons are useful because they are the patient's own words, and one of the therapists quoted in the article puts the underlying problem plainly: the one to three hours a week a patient spends in therapy "pales in comparison to the 168 hours we have in a given week."

The peer-reviewed literature tells a more complicated story than "patients forget". That matters, because if you misread why a patient skips their exercises, you will reach for the wrong fix.

What the research links to home exercise adherence

Four studies are worth knowing in detail. None of them is specific to hand therapy, so read them as general physiotherapy evidence that you will need to test against your own caseload.

Essery 2017: belief in oneself, motivation and support

Essery and colleagues systematically reviewed 30 quantitative studies on home-based, self-managed physical therapies. The useful part is what predicted adherence. The review found relatively strong evidence for five factors:

• the patient's intention to do the program
• self-motivation
• self-efficacy (confidence that they can actually do it)
• previous adherence to exercise-related behaviors
• social support

Notice what is not on that list: reminders. Forgetting may be the reason patients give, but the stronger predictors sit underneath it, in confidence, motivation and the people around them.

Bachmann 2018: fewer exercises, more support

A second systematic review, by Bachmann, Oesch and Bachmann, looked for factors that help and turned them into recommendations. Adherence was supported by intensive social support and guidance from the physiotherapist, by prescribing a low number of exercises (fewer than four), by high self-motivation and self-efficacy, and by the absence of psychological factors such as helplessness, depression and anxiety. The authors conclude that adherence could be improved "relatively simply": good support from the physiotherapist, two to a maximum of four exercises, and work on the patient's self-motivation and self-efficacy.

The exercise count is the finding most worth acting on, because it is the one entirely in your hands. A sheet of eight exercises looks thorough. It may also be the reason none of them get done.

Sluijs 1993: barriers, feedback and helplessness

Sluijs, Kok and van der Zee is old, but it is unusually large and grounded in everyday practice. Of a random sample of 300 physical therapists in private practice in the Netherlands, 222 responded; the material included 1,931 registration forms, 1,837 audio-recorded therapy sessions and 1,681 patient questionnaires.

Three factors were most strongly related to non-compliance:

1. the barriers patients perceive and encounter (the strongest relation)
2. a lack of positive feedback
3. helplessness

The authors' advice for practice is worth quoting almost in full: therapists should "carefully explore which problems patients encounter in their efforts to comply" and "seek solutions to those problems in mutual cooperation with their patients." It is a correlational study, so it cannot show cause and effect, but it points to things a clinician can change in the next session.

Campbell 2001: patients' decisions are rational

Campbell and colleagues interviewed 20 people with knee osteoarthritis at home, three months after a physiotherapy program, and eight of them again a year later. It is a small qualitative study, and knees are not hands, but its central point travels well.

Initial compliance was high, largely out of loyalty to the physiotherapist. Whether people kept going depended on whether they could fit the exercises into everyday life, how severe their symptoms felt, their attitudes to arthritis, other health problems and earlier experiences. One condition was necessary for continued compliance: the patient had to perceive that the exercises were relieving unpleasant symptoms.

The conclusion is the line to remember: "From the patient's perspective, decisions about whether or not to comply are rational but often cannot be predicted by therapists or researchers." A patient who stops because their hand feels better, or because they do not believe the exercises help, is making a reasoned choice. Calling it "non-compliance" does not change that reasoning; a conversation might.

Adherence is multifactorial, so no single fix works

Put the four studies side by side and the factors fall into roughly four groups:

• The person: self-efficacy, self-motivation, helplessness, low mood and anxiety.
• Their life: time, routine, practical barriers, social support.
• Their beliefs: whether the exercises seem to work, how serious the problem feels, earlier experiences.
• The program and the care around it: how many exercises, how much guidance, and whether anyone notices and acknowledges the effort.

Most digital tools, including reminder apps, mainly touch the last group, and only part of it. That is not a reason to dismiss them, but it should temper expectations. The one hand-specific trial we found makes the point. In a Swedish randomized trial of 101 patients after flexor tendon repair, a smartphone app with exercise videos, push notifications and an exercise diary did not improve adherence or self-efficacy compared with standard rehabilitation. The app group did report a higher exercise frequency at six weeks, but the overall picture was no better.

A tool can plausibly help with three behavioral pieces: making a short program easy to start, giving feedback during the exercise, and making it visible whether the exercises happened. It cannot make a patient believe the program works, find them time in a chaotic week, or lift helplessness. Those still sit with you.

What you can do in the clinic

None of this is a protocol. These are practical moves that follow from the studies above, for you to adapt.

1. Ask about barriers by name. Instead of "How did the exercises go?", ask "What got in the way?" Sluijs found perceived barriers had the strongest relation with non-compliance, and the authors' advice was to explore them and solve them together.
2. Prescribe fewer exercises. Bachmann's review supports two to four. If everything feels essential, ask which two you would keep if the patient could only manage two.
3. Give specific positive feedback. A lack of positive feedback was one of Sluijs's three main correlates. "You've clearly been doing these, the movement is smoother" costs ten seconds.
4. Build confidence before they leave. Self-efficacy shows up in both reviews. Let the patient do each exercise in front of you until they can do it without prompting, and ask how confident they feel doing it alone.
5. Explain why, then check whether they think it is working. Campbell found that perceived benefit was a precondition for continuing. If a patient does not see the point, or thinks they are done because things feel better, talk about it openly.
6. Attach the exercises to an existing routine. Forgetting and lack of time topped the survey. Ask when in their day the exercises could happen, and tie them to something that already happens then.
7. Involve the people around them. Social support appears in both systematic reviews. A partner or family member who knows the plan can help.
8. Notice helplessness and low mood. Bachmann and Sluijs both point to psychological factors. A patient who feels nothing they do makes a difference needs a different conversation than one who simply ran out of time.
9. Make the gap between visits visible, and be honest about what that achieves. Some patients say there is no accountability between appointments. A simple way to see whether exercises happened gives you something concrete to discuss, but as the Swedish trial shows, visibility alone does not guarantee better adherence.

The honest summary for clinicians is short. Patients skip home exercises for reasons that are mostly sensible from where they sit: too many exercises, too little confidence, no sign that it helps, a life that does not have room for it. The research points less towards better reminders and more towards fewer exercises, more feedback and a direct question about what got in the way.