Behaviour change in physiotherapy
Have you ever questioned why you couldn’t get your rehab done?
Maybe you’d do your exercises for a few days and then completely forget about them. Or you’d leave your physio appointment genuinely intending to do everything you were given, only for work, kids, training and life to take over.
Well, you’re not alone. And it might have less to do with being “unmotivated” than you think.
Behaviour change is hard. Knowing what you should do and actually doing it consistently are two very different things. That’s why rehabilitation can’t just be about finding the perfect exercise. We also need to understand the person who is supposed to do it.
Behaviour change has been one of the pillars of how we approach rehabilitation at By Design since we opened. That’s because rehabilitation doesn’t happen during the 30 or 45 minutes someone spends with their physiotherapist. It happens during all the other hours of their week. You can prescribe what looks like the perfect rehabilitation program, but if someone leaves the clinic and never does it, it isn’t a very useful program.
Whether someone repeatedly trains through a flare, completely stops activity because they’re frightened of pain, forgets their exercises or simply struggles to fit rehabilitation into an already busy life, behaviour influences what happens next. Exercise prescription is often the easy part. Helping a human being actually implement it is where things get interesting.
Behaviour change was a significant part of my physiotherapy education at James Cook University. Our training had strong links with the hospital and broader healthcare environment, so we spent time learning about behaviour change, psychological strategies and concepts drawn from approaches such as cognitive behavioural therapy. Physiotherapy education and practice now also has a strong exercise science influence, which is incredibly valuable, but knowing how to prescribe and progress exercise is only one part of rehabilitation. We also need to understand the person who is supposed to perform it.
There are established frameworks that can help us think about this. One is the COM-B model, which proposes that behaviour is influenced by three broad things: Capability, Opportunity and Motivation. Does the person physically and psychologically feel capable of doing what we’re asking? Do they actually have the opportunity, time, equipment, environment and support to do it? And do they have sufficient motivation for the behaviour to occur? If one of those pieces is missing, simply telling someone to try harder isn’t particularly useful. We need to understand which part of the system is getting in the way.
Another useful framework is the Stages of Change, sometimes called the Transtheoretical Model. Not everyone who walks into a physiotherapy clinic is at the same point in their willingness or readiness to change. Someone may be in pre-contemplation, where they aren’t really considering changing their behaviour yet. They might be sitting in front of us because their partner, doctor or employer told them to come, or because pain has finally forced them to seek help. Someone in contemplation may recognise that something needs to change but hasn’t committed to doing it. In preparation, they’re beginning to work out how they’ll make the change. In action, they’re actively implementing it. Eventually, the aim is for those behaviours to become sustainable enough to move towards maintenance.
That distinction matters enormously in physiotherapy. Imagine giving a five-exercise rehabilitation program to someone who hasn’t yet decided they want to exercise. Compare that with someone who already trains four days a week, understands why rehabilitation matters and is asking you exactly where to put their exercises into their program. Those two people could have exactly the same diagnosis and physical findings, but they may need completely different physiotherapy. One might need education, reassurance and one incredibly simple starting behaviour. The other might need a detailed loading progression and the independence to run with it.
This is something I’ve learnt through more than just physiotherapy. I’ve read widely around behaviour and habit formation, including books such as Atomic Habits. I train myself and know how difficult disciplined action can be when life gets busy. Before By Design, I also spent years around people in hospitality while owning bars, cafes and a restaurant. And after more than a decade of treating clients, one thing has become incredibly obvious: people have lives. They have kids, businesses, work, social commitments, fatigue, stress and a hundred things competing for their attention. Once someone walks out of the physio room, there’s a good chance they won’t think about their rehabilitation again until their symptoms remind them or their next appointment appears in the calendar. That isn’t necessarily a lack of commitment. It means rehabilitation has to compete with real life.
That’s why understanding the person matters as much as understanding their diagnosis. When could this exercise realistically happen? Could we attach it to something they already do, such as brushing their teeth, making their morning coffee, going to the gym or finishing work? What barriers are likely to get in the way? Does this person actually want a home exercise program? Do they need accountability? Would they be more consistent doing their rehabilitation in the gym? If someone returns several times and repeatedly hasn’t completed their exercises, simply adding another exercise to the list probably isn’t the solution. Sometimes we need to do the opposite. Strip the program back. Give them one or two things that matter. Make those things achievable and build from there.
One of our physiotherapy principles at By Design is coaching over prescription. We don’t want to demonstrate an exercise once, hand someone a program and assume they’ll work it out. People need practice. They need feedback and patience. This becomes even more important for someone who hasn’t spent years in a gym and doesn’t naturally understand what a particular movement is supposed to feel like. We might only complete two rounds of an exercise together in the clinic, but we want those two rounds to teach something. Where should you feel it? What should you look for? What happens if it feels uncomfortable? What’s an acceptable response and what tells you to modify it? Can you confidently reproduce this when we’re no longer standing beside you?
That changes rehabilitation from simply prescribing sets and reps into teaching someone how to manage their body. Exercise quality matters, but so does understanding. We want people to leave knowing what they’re doing, why they’re doing it and how to adjust when things don’t go perfectly. Humans need practice, particularly when they’re learning a completely new movement or rebuilding confidence after pain or injury.
Behaviour change also doesn’t mean manipulating someone into doing what the physiotherapist thinks is best. The plan still belongs to the person. Our job is to understand where they’re currently at and meet them there. If someone genuinely doesn’t want to exercise at home, we need to know that. If five exercises aren’t going to happen but one will, let’s find the one that matters most. If they need more regular coaching initially, let’s provide it. If they’re highly independent and ready to take action, give them the tools and let them run with it.
At By Design, we try to make that process simple and effective. Understand the person. Work out their current readiness for change. Identify what might be limiting their capability, opportunity or motivation. Find the right exercise. Practise it. Make sure they understand it. Attach it to something that already exists in their life where possible. Identify the barriers early. Reassess whether it actually happened. Then work out whether it actually helped.
Because the best rehabilitation program isn’t necessarily the one with the most sophisticated exercises.
It’s the one the person understands, is ready to engage with and can actually fit into their life.
Want rehabilitation that actually fits your life?
Your rehabilitation plan needs to work outside the clinic, not just look good on paper. We’ll consider your goals, routines, barriers, training experience and where you’re currently at when deciding what your rehabilitation should look like.
Work with the By Design physiotherapy team in North Hobart and build rehabilitation you can actually use.
