Why Patients Don’t Do Their Exercises and What Behavioural Economics Can Teach Us

If you’ve spent more than a week in clinical practice, you know the problem: most patients don’t do their home exercises, and I don’t blame them. Many exercise programs are boring as bat…, given without context and explanation quickly at the end of a session, and aren’t curated to the patient’s needs. But that’s another problem, entirely.

Adherence rates can dip as low as 30%. That’s not a small problem. If we subscribe to the trope that ‘the best exercise is the one that gets done’, this is a pivotal issue facing MSK clinicians.  Whether the goal is strength, balance, aerobic conditioning or falls prevention, the bulk of change happens outside the clinic. So why do patients struggle so much?

Behavioural economics offers a surprisingly helpful answer (1).

Behavioural economics studies how humans behave and make decisions. Patients aren’t lazy or unmotivated. They’re human. And humans are wired to prioritise the immediate, the easy, and the rewarding. Home exercise rarely fits that bill.

The good news: behavioural economics can offer solutions: simple, low-cost strategies that help patients turn intention into action.

1. Make it matter (really matter)

We often tell patients that exercise improves mobility, strength or capacity. Sensible, but abstract. Behavioural economics tells us that gain-framed, personally meaningful outcomes are far more motivating.

“Improved mobility” doesn’t compete well with Netflix at 8pm.
“Being able to play with your grandchildren without pain” stands a beter chance.

When a patient defines a tangible, emotionally relevant goal, it becomes a natural cue in daily life, a reminder that their effort has purpose and is attached to a greater goal.

2. Be selective, together

More exercises ≠ better adherence. In fact, the opposite is true.
Patients given six (or more) exercises are less likely to adhere than those given three or fewer.

Simplicity wins.

And co-design wins even more. Asking patients to choose the exercises they prefer increases autonomy, self-efficacy and commitment, all powerful behavioural drivers.

A short, collaborative, enjoyable program outperforms a perfect but overwhelming one every time.

3. Plan for the future: don’t hope, design

Patients routinely overestimate how easy it will be to complete their exercises. They leave the clinic optimistic and return next week sheepish.

Behavioural economics calls this the intention–action gap.

Three tools help bridge it:

Planning prompts

Get patients to specify when, where and how they’ll complete their exercises. This shifts adherence from vague intention to concrete plan.

Habit stacking

People are creatures of routine. Linking a new behaviour to an existing one (“after brushing my teeth, I do my exercises”) anchors it in an established neural circuit.

Temptation bundling

Pairing an unenjoyable behaviour with a pleasurable one: music, podcasts, calling a friend, TV, increases follow-through. I personally can only survive my weekly long run on the tready with the assistance of YouTube or Netflix.

Make the exercise session something to look forward to.

4. Maintain the streak

The humble tick-box calendar or habit-tracking app works.
Why? Because streaks are motivating. Humans hate breaking them.

Streak tracking:

• provides visible progress
• rewards participation, not outcomes
• encourages consistency without perfectionism

It is deceptively simple and surprisingly effective.

5. Don’t catastrophise setbacks

Patients will miss days. Holidays, illness, fatigue, life.
The mistake is treating a missed day as failure.

Behavioural evidence shows that flexibility improves consistency. Helping patients recover quickly, rather than judge themselves, protects long-term adherence.

Leverage fresh-start effects: new week, new month, new year, new birthday, all compelling reset points.

What this means for clinicians

Behavioural economics doesn’t replace therapeutic alliance, education or skilled exercise prescription. It complements them. It acknowledges the reality of human behaviour and equips us to work with it, not against it.

In practice:

• Anchor goals to what really matters to the patient
• Keep programs short and co-designed
• Use planning prompts and habit-stacking
• Encourage streak tracking
• Normalise setbacks and leverage resets

Small changes, big behavioural shifts.

Clinicians often worry about program complexity, exercise selection and biomechanics. But the biggest determinant of success might be far simpler: can the patient consistently do what we’ve asked them to do?

Behavioural economics shows us how to make that far more likely.

Reference

1. Altinger G, Maher CG, Traeger AC. Using behavioural economics to improve adherence to home exercise programs. J Physiother. 2024;70(3):161–3.