Exercise as prescription versus advice: The impact of structured programs on adherence in outpatient physiotherapy

S. Hemakumar*

Physiotherapist & Clinician, Kauvery Hospital, Alwarpet. Chennai, Tamil Nadu

*Correspondence

Abstract

Background: In outpatient physiotherapy, exercises are often perceived by patients as optional advice rather than structured treatment. This perception reduces adherence and undermines functional recovery.

Objective: To evaluate the impact of shared decision making (SDM) and prescription-style framing of exercises on patient adherence and outcomes in an outpatient physiotherapy department.

Methods: An observational study of 46 patients of age 25–70 attending OPD physiotherapy was conducted. Patients were engaged in SDM through expectation mapping, information exchange, and joint goal setting. Exercises were delivered either as advice or as prescriptions with defined dosage, rationale, and progression. Adherence and functional outcomes were measured across both groups.

Results: Adherence was significantly higher when exercises were framed as prescriptions (74%) compared to advice (42%). Functional scores improved more in the prescription group, with patients reporting greater confidence and accountability. Qualitative feedback highlighted that patients valued being “part of the decision,” while therapists observed stronger trust and reduced dropouts.

Conclusion: Shared decision making, combined with prescription-style framing of exercises, enhances patient engagement, adherence, and functional recovery in OPD physiotherapy. Reframing exercises as prescriptions legitimizes physiotherapy as frontline care and positions it alongside pharmacological treatment in modern healthcare practice.

Keywords: Shared decision making; Outpatient physiotherapy; Exercise prescription; Patient adherence; Functional outcomes

Introduction

Outpatient physiotherapy is a cornerstone of musculoskeletal care, where exercise-based interventions are routinely prescribed to restore mobility, reduce pain, and promote long-term functional recovery. Despite their central role, patients often perceive these exercises as optional advice rather than structured treatment, which undermines adherence and limits therapeutic effectiveness. This disconnection between patient expectations and therapist priorities creates a challenge in ensuring continuity of care and achieving meaningful outcomes.

Shared decision making (SDM) offers a practical solution by aligning clinical reasoning with patient preferences. Through expectation mapping, information exchange, and joint goal setting, SDM empowers patients to actively participate in their treatment plan. When exercises are framed as prescriptions with defined dosage, rationale, and progression they gain legitimacy comparable to pharmacological interventions, fostering accountability and adherence.

The aim of this study was to evaluate whether integrating SDM with prescription-style framing of exercises improves patient engagement, adherence, and functional outcomes in an outpatient physiotherapy department.

Patient profile

  • Sample: 46 patients (ages 25–70).
  • Setting: Physiotherapy OPD, multispecialty hospital.
  • Referral reasons: Pain relief, mobility restoration, post-discharge continuity.

Clinical challenge

Patients expected quick relief or simple tips, while therapists prioritized structured assessment and long-term functional goals. This mismatch risked disengagement.

Methods: Shared Decision-Making Approach

Study design

This was a case study conducted in the outpatient physiotherapy department of a multispecialty hospital. The study explored how shared decision making (SDM) and prescription-style framing of exercises influenced patient adherence and functional outcomes.

Participants

A total of 46 patients, aged 25–70 years, were included. All patients presented with musculoskeletal complaints such as low back pain, mobility limitation, or post-discharge continuity needs. Patients provided informed consent prior to participation.

Setting

The study was carried out in the physiotherapy outpatient department (OPD), where patients typically attend for pain relief, functional restoration, and follow-up care after hospital discharge.

Intervention

  • Patients were divided into two groups based on how exercises were delivered
  • Advice group: Exercises were explained verbally as general recommendations.
  • Prescription group: Exercises were documented and communicated as prescriptions, including dosage (sets, repetitions, frequency), rationale (mechanism of benefit), and progression (planned increases in intensity).

Shared decision-making approach

SDM was embedded into all consultations through

  • Expectation mapping: Patients were asked, “What matters most to you today?”
  • Information exchange: Therapists explained available options and clarified the role of exercises as treatment.
  • Joint goal setting: Patients and therapists co-created individualized exercise plans.
  • Prescription framing: In the prescription group, exercises were written down and presented with clear instructions, like a medical prescription.

Outcome measures

  • Adherence: Measured by patient-reported completion of prescribed/advised exercises at follow-up.
  • Functional outcomes: Assessed using standardized mobility and pain scores recorded during OPD visits.
  • Qualitative feedback: Collected through patient comments and therapist observations regarding engagement, trust, and satisfaction.

Results

Quantitative findings

Adherence rates were significantly higher in the prescription group compared to the advice group. In the prescription group, 74% of patients reported completing their exercises as directed, whereas only 42% of patients in the advice group adhered to the recommendations. Functional scores also improved more in the prescription group, with 65% demonstrating measurable gains in mobility and pain reduction compared to 38% in the advice group.

Table 1. Adherence and functional improvement by group

GroupAdherence (%)Functional Improvement (%)
Advice framing4238
Prescription framing7465

Qualitative findings

Patient consistently reported greater confidence and accountability when exercises were prescribed with dosage and progression. Several patients expressed that written instructions made them view exercises as “treatment” rather than optional advice. Therapists observed stronger trust, reduced dropouts, and improved engagement when shared decision making was integrated into consultations.

Fig (1): Patient perceptions of exercise framing

Discussion

This case study demonstrated that exercises framed as prescriptions, rather than advice, significantly improved adherence and functional outcomes in outpatient physiotherapy. Patients who received structured, written exercise plans with dosage and progression were more likely to complete their programs and reported higher satisfaction. These findings reinforce the wider evidence that patient engagement increases when physiotherapy interventions are communicated with the same clarity and authority as pharmacological treatments.

Shared decision making (SDM) was central to bridging the gap between patient expectations and therapist priorities. By inviting patients to articulate their goals, therapists were able to tailor interventions that aligned with individual needs. This collaborative approach transformed the therapeutic relationship from directive to participatory, fostering trust and accountability. The improvement in adherence observed here is consistent with previous studies showing that SDM enhances motivation and self-efficacy in musculoskeletal rehabilitation.

The distinction between exercise as advice and exercise as prescription is clinically meaningful. Advice implies optionality, whereas prescription conveys necessity and structure. When exercises are prescribed with dosage, rationale, and progression, patients perceive them as legitimate treatment, reinforcing physiotherapy’s role as frontline care. This reframing also strengthens continuity of care, particularly in outpatient settings where follow-up depends on patient self-management.

These findings contribute to the broader physiotherapy literature by emphasizing the importance of communication framing and patient partnership. They highlight that effective physiotherapy is not only about technical skill but also about how interventions are presented and co-owned. Embedding SDM and prescription-style documentation into routine OPD practice can enhance adherence, satisfaction, and long-term outcomes.

Conclusion

Objective: This study evaluated whether shared decision making (SDM) and prescription-style framing of exercises improve adherence and functional outcomes in outpatient physiotherapy.

Key findings: Among 46 patients, adherence and functional improvement were significantly higher when exercises were presented as prescriptions rather than advice. Patients reported greater confidence, accountability, and satisfaction when actively involved in decision making, while therapists observed stronger engagement and continuity of care.

Significance: These findings underscore that physiotherapy outcomes depend not only on clinical expertise but also on how interventions are communicated. Framing exercises as prescriptions legitimizes physiotherapy as structured treatment, reinforcing its role as frontline care. Integrating SDM into routine OPD practice fosters patient partnership, enhances adherence, and supports long-term recovery.

Limitations: The study was limited by its single-center design and modest sample size, with no long-term follow-up to assess sustained adherence.

Future Work: Larger, multi-center studies with extended follow-up are needed to validate these findings. Exploring digital or visual prescription tools may further strengthen patient engagement and documentation consistency.

Closing statement: In conclusion, shared decision-making transforms physiotherapy from a directive process into a collaborative partnership. When exercises are prescribed with clarity, rationale, and progression, they become a symbol of trust and accountability advancing physiotherapy’s identity as a reasoning-based, patient-centered discipline.

References

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  • Moore CL, Kaplan SL. Framework and resources for shared decision making: opportunities for improved physical therapy outcomes. Physical Therapy. 2018;98(12):1022–1036. doi:10.1093/ptj/pzy095
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