Physiotherapists prescribe behaviours every day: exercise, walking, pacing, symptom monitoring, sleep routines and gradual return to valued activities. 

These recommendations may be clinically sound but they still have to survive real life. 

When action does not follow advice, it is tempting to think the patient lacks motivation. 

Sometimes motivation is part of the issue. 

However, the COM-B model, which explains behaviour as the interaction between capability, opportunity and motivation, offers a useful clinical reminder: action depends on more than motivation alone (Michie et al 2011). 

Rather than asking, ‘Why didn’t the client comply?’ it may be more useful to ask, ‘Where did the behaviour break down and how can we redesign the plan so that it fits the person and their context better?’ 

Make the behaviour specific

A vague recommendation is hard to act on. ‘Be more active’ may be clinically reasonable but it gives the patient very little to hold on to. 

What counts as active? How should it be done? How much is enough? 

Research on goal setting and implementation intention suggests that people are more likely to act when goals are specific and when the timing, location and action are clear (Epton et al 2017, Gollwitzer & Sheeran 2006). 

In practice, this means shifting from a broad goal to an observable behaviour. 

Instead of ‘Walk more’, the plan might be ‘Walk for five minutes on workdays’. Instead of ‘Do your exercises’, it might be ‘Complete one set of calf raises’. 

This does not make the plan simplistic. It makes it executable. 

Attach it to a cue 

Habits are shaped by repetition in stable contexts. 

A behaviour is more likely to become automatic when it is repeated in response to a consistent cue, such as a time of day, location, existing routine or familiar event (Lally et al 2010). 

For physiotherapy, this matters because many home programs rely too heavily on memory and motivation. 

A patient who is asked to ‘remember to do your exercises three times per week’ has to keep making a fresh decision. A patient who is asked to do one set after making their morning coffee has a cue already built into the day. 

Useful cues are usually ordinary: brushing teeth, making coffee, arriving home or finishing lunch. 

‘Complete one set of calf raises’ becomes ‘After brushing your teeth, complete one set of calf raises at the bathroom sink’; ‘Walk for five minutes on workdays’ becomes ‘Walk for five minutes after lunch on workdays’. 

Make it easier 

Physiotherapists prescribe dosage to maximise clinical effect. But even the best dose has limited value if the patient cannot perform the action consistently. 

Good behaviour design includes a minimum version: the smallest useful action the patient can complete when symptoms, time or confidence get in the way. 

This keeps the routine alive and protects momentum. This is especially useful when pain, fear, fatigue, low confidence or competing demands are present. 

Physiotherapy adherence research has identified barriers such as pain during exercise, low self-efficacy, anxiety, depression and limited social support (Jack et al 2010). 

Self-efficacy matters because people are more likely to persist with a behaviour when they believe they can perform it successfully (Bandura 1977). 

A minimum version might be two repetitions, one minute, one set or a gentler variation. 

The target might be two sets of sit-to-stands but the minimum might be five smaller-range repetitions on a flare day. 

This is not about lowering expectations. It is about protecting continuity. 

A small action repeated consistently may build confidence and momentum. It also gives the physiotherapist better information at review: was the barrier the load, symptoms, timing, confidence or something else? 

Reduce friction 

Behaviour does not happen in a vacuum. 

COM-B frames opportunity as the physical and social environment around a behaviour; even a motivated patient may struggle if the plan is inconvenient, unclear or poorly supported (Michie et al 2011). 

Small sources of friction can be enough to stop a behaviour: equipment in another room, a plan that takes too long, fear about pain, uncertainty about technique or a program that requires privacy in a crowded home. 

None of these are failures of character. They are design problems. 

The behaviour change technique taxonomy includes strategies such as action planning, prompts and cues, problemsolving, restructuring the environment, self-monitoring and feedback (Michie et al 2013). 

In practice, these become simple adjustments: clarify the location, simplify equipment, define an acceptable symptom response, create a fallback option and remove unnecessary steps. 

Use feedback 

It is important to build feedback into the plan. 

Feedback creates a record that the patient and physiotherapist can review together over time.

It helps make progress, setbacks and contributing factors more visible so the plan can be progressed, modified or redesigned.

This is consistent with established behaviour change techniques such as self-monitoring, feedback and review, which help turn experience between appointments into information that can guide the next clinical decision (Michie et al 2009, Michie et al 2013).

Feedback does not need to be complex. It can be a tick on a calendar, symptom response, confidence rating, step count, walking distance or subjective measures such as ‘stairs felt easier’. 

The aim is to make the behaviour visible enough to review, not to create more administration for its own sake. How we discuss feedback is also important. 

Instead of asking, ‘Did you do your exercises?’ we can ask, ‘Did our plan work and what happened when you tried to follow it?’

This changes the tone from inquisition to collaboration and makes any non-adherence useful information rather than failure. 

A behaviour prescription 

One way to bring these ideas together is to add a brief ‘behaviour prescription’ to the clinical plan. A behaviour prescription briefly defines the action, anchor, target dose, minimum version, likely friction, fallback option, feedback and review point. 

For example, instead of saying, ‘Do your strengthening exercises three times per week’, the plan might become: 

‘After breakfast on Monday, Wednesday and Friday, do one set of sit-to-stands at the kitchen chair. 

Aim for eight repetitions at a moderate effort. If pain or stiffness is higher than usual, do five smaller-range repetitions instead.

Record it with a tick on the calendar and we will review what happened next visit.’ 

In this way, the exercise is not new. What has changed is the supportive design around it, giving the patient a better chance of success. 

Keeping behaviour design person-centred 

Behaviour design works best when it is personalised. 

Two patients may receive the same exercise but need very different plans to make it happen. 

One may need a smaller starting point because their confidence is low. 

Another may need a cue that fits around shiftwork. Another may need a fallback option for symptom changes, caring responsibilities or limited space at home. 

This is why the plan needs to be codesigned. 

The physiotherapist brings clinical reasoning about what is likely to help; the patient brings knowledge of their own life, values, routines and barriers. 

Bringing those together makes the behaviour more realistic and more likely to be continued, adapted and progressed over time. Physiotherapists are already skilled at deciding what intervention may help. 

The opportunity is to become equally deliberate about designing how that intervention will be carried into daily life. The best home program is not simply the most complete or research-informed program on paper. 

It is the one the patient can do, build on and use as a step toward better health and a better life. 

Find the references here.

Pete Haynes is a physiotherapist and allied health educator in Albury, New South Wales. 

His writing explores healthcare, technology and clinical practice.