Written by Angela Rivera,
Home exercise programs (HEPs) are essential for physical therapy success, yet adherence to HEPs remains a persistent challenge in rehabilitation. Even when patients understand their plan and express initial commitment, follow-through is rather abysmal. Some studies estimate non-adherence can go as high as 70%.
Telehealth has only complicated things for physical therapy. When there’s no physical presence, you have to rely entirely on observation, instruction, and patient self-report to guide performance. All flawed or incomplete data.
Still, there’s no doubt that telehealth offers advantages to both therapists and patients. You gain direct insight into the patient’s home environment (where adherence either succeeds or fails), and the patient enjoys greater comfort and convenience. Considering these advantages, why is adherence to HEPs so low?
Most breakdowns can be traced to two factors: patient-specific barriers (personal reasons) and program design flaws or limitations. While you cannot eliminate every personal constraint, you can significantly improve outcomes by refining how you design, teach, and monitor HEPs over video. Below, we outline structured, telehealth-ready approaches to help you do exactly that.
Video Coaching Changes How HEP Actually Works
Before we get to the practical coaching advice, let’s cover the basics first: how does video actually change HEP in practice? Setting aside, obviously.
Perhaps the most important change comes from your own clinical reasoning. Namely, video forces you to rely on observation and communication (instead of tactile cues) as your primary means of intervention. That means that any subtle compensations that you might correct instinctively in person now have to be noticed earlier and described clearly (and briefly enough that the patient can act on them).
Having said that, with video, you gain insight into something that rarely exists in clinic-based care: a patient’s home environment and therefore context you can trust. When you see the patient’s environment (the chair they always use, the limited space in a hallway, the distractions that compete for their attention, etc.), you’ll be able to quickly tell whether they’ll be able to adhere to the program or not. And that information will allow you to adjust it so it fits into the patient’s day instead of competing with it.
In other words, video coaching forces greater precision. Here, you can’t just prescribe exercises as you would in-person; you have to prescribe exercises while keeping in mind they will be carried out when you’re not there. So, small decisions like the camera angle, wording of a cue, or how many exercises you assign carry more weight than they might in person.
What “High-Quality” Means in a Home Exercise Program
Most adherence problems don’t start with patient motivation but with vague or impractical programs. If the HEP isn’t specific, adaptable, and easy to interpret without you there present, patients are bound to improvise or simply disengage.
The cure is a clear, high-quality HEP, one that tells the patient exactly what to do, how to do it, and what to expect when they do it correctly (and incorrectly).
At a minimum, your HEP should include:
- Clearly defined exercises with dosage (sets, reps, tempo, rest)
- A stated purpose (what impairment or function you’re targeting)
- Symptom boundaries (what level of discomfort is acceptable)
- Progression criteria tied to observable changes
- A schedule that fits into the patient’s existing routine
But structure alone isn’t enough. The program also needs to anticipate friction. What happens if pain increases? What if the patient misses a day? What if they’re unsure whether they’re doing it correctly?
These questions cannot go unanswered if the goal is adherence. For a deeper look at how to build and refine these elements, including practical examples, you can refer to this guide on physical therapy home exercise programs, which expands on progression strategies and patient education in more detail.
Think of what we outlined here as your baseline. Everything that follows builds on how well this foundation holds up when you’re not physically present.
Screen for Risk and Constraints Before the Session Starts
To start, you want to make sure there are no surprises, so have a brief pre-visit screen that covers clinical risk and environmental constraints.
avoid any potential surprises and problems.
Before the session, screen for:
- Cardiovascular or neurological red flags
- Fall risk (especially for balance or gait tasks)
- Pain irritability levels
- Equipment availability
Ask direct questions: Where will you be doing the exercises? How much space do you have? What surface are you standing on? Do you have a stable chair or support within arm’s reach? These details determine whether your plan is feasible, not just appropriate on paper.
Also, during the session, confirm the patient’s physical location and an emergency contact protocol. If a patient becomes symptomatic (dizziness, acute pain, loss of balance, etc.), you need a clear plan for what happens next. Telehealth guidelines emphasize location verification and contingency planning as part of safe remote care, so this step is non-negotiable.
Set Up the Camera Like It’s a Clinical Tool
Poor camera positioning can undermine your assessment because you can’t correct what you can’t see clearly.
Ask the patient to:
- Position the camera at joint level when possible
- Use landscape orientation for full-body movements
- Ensure adequate lighting from the front (not behind)
- Keep enough distance to capture full movement arcs
And test it by spending the first few minutes adjusting angles. It takes a few moments only, but pays off later when you’re cueing subtle movement errors.
Demonstration Still Matters But It Needs Structure
Demonstrations are important, but they should be concise and purposeful. Long, uninterrupted explanations are actually counterproductive.
So, break it into steps:
- Show the full movement once at normal speed
- Repeat at a slower pace with key cues
- Highlight common errors (and how to fix them)
Then switch quickly to patient performance. The longer you talk, the less time they practice.
And consider your positioning because some patients struggle to repeat the exercise when switching from your orientation to theirs. You can help this by demonstrating from the same orientation they will use. Or, by explicitly stating left/right to avoid confusion.
Refine Your Cueing Strategy
Without tactile input, your words carry the intervention so they need to be clear and impactful.
Use:
- External cues (“push the floor away”) rather than internal ones (“activate your glutes”)
- Short phrases, not paragraphs
- One correction at a time (cue after cue overwhelms patients)
And ask for feedback. A simple question like “What did that feel like?” often reveals whether your cue worked.
Of course, mirror neurons still play a role in video learning, but clarity matters more. Usually, patients don’t need more information, but the right information at the right moment.
Build in Adherence Tactics from the Start
Research shows that tailored programs and regular follow-up improve adherence significantly. So one of your main goals should be customization of the program so it’s tailored to your patient’s life.
The best way to do this is to tie exercises to your patient’s existing routines. So, instead of asking patients to “find time” for the HEP, attach exercises to their existing routines like morning coffee or evening TV.
For example, you can ask a patient with knee osteoarthritis to perform sit-to-stand repetitions immediately before meals, using the same kitchen chair each time. Or schedule thoracic mobility or cervical exercises directly after computer work sessions, when symptoms are typically most noticeable.
And use simple tracking tools:
- Paper logs (still effective)
- Mobile apps with reminders
- Brief check-ins between sessions
Documentation and Tracking Outcomes
Telehealth documentation requires the same rigor as in-person care. In fact, it requires a few extra steps.
Include:
- Patient location and consent
- Technology used (platform, any issues)
- Objective findings based on visual assessment
- Patient-reported outcomes
- HEP details and progression criteria
And if you’re tracking continuing education (CE) or competency logs, make sure your documentation aligns with measurable outcomes. It’s key to making your records actually usable for both clinical and professional development purposes.
Speaking of tracking outcomes, make sure you track those that actually matter, not every single detail. This includes pain levels (standardized scales), functional measures (like sit-to-stand reps, timed walks, etc.), patient-reported confidence or perceived effort, and finally, adherence.
And review these metrics with the patient. When they see progress, adherence improves.
Another thing outcome tracking helps with: your own progression decisions. With real, usable data, you can move from guesswork to data-driven adjustments.
Adapt for Different Abilities and Access Levels
Since not every patient will have the same technology, space, or physical capacity, you need to adapt your plan to each individual.
You can do this by planning for:
- Low-bandwidth options (audio-only backup, simplified visuals)
- Limited equipment (bodyweight alternatives)
- Cognitive or language barriers (simpler instructions, visual aids)
And consider equity. Patients in rural or underserved areas may rely heavily on telehealth. Your ability to adapt directly affects their access to care. Digital literacy also varies, so spend time early on teaching patients how to use the platform.
Use Asynchronous Support Between Sessions
Video sessions don’t have to carry the full burden.
Between visits, you can:
- Send short instructional videos
- Provide written summaries of the HEP
- Offer quick feedback on recorded patient performance
If your goal is better continuity, take this hybrid approach. With it, patients won’t feel “on their own” between sessions, which supports adherence.
Anticipate Common Failure Points
Some issues repeat across patients.
Expect:
- Overload
- Unclear instructions
- Pain flare-ups without guidance
- Scheduling conflicts
Address these proactively by limiting the number of exercises, clarifying stop rules, and offering flexible scheduling options (if possible).
Treat Video Coaching as a Skill
With video coaching, you don’t get the same tools as in-person care. That’s obvious. But you gain others, including direct visibility into the patient’s daily environment and a clearer sense of what will realistically happen once the session ends.
So approach video coaching as its own clinical skill set. The quality of your cueing, exercise selection, follow-up, and progression planning carries more weight when the patient performs most of the work independently.
In many cases, telehealth exposes weaknesses in HEP design faster than in-person care because patients cannot rely on constant correction or supervision. So it forces you to build programs that patients can actually understand, repeat, and sustain without you in the room. And ultimately, that is the real test of whether a home exercise program works.
References:
American Physical Therapy Association. (2020). Telehealth in physical therapy in light of COVID-19.
Cottrell, M. A., Galea, O. A., O’Leary, S. P., Hill, A. J., & Russell, T. G. (2017). Real-time telerehabilitation for the treatment of musculoskeletal conditions is effective and comparable to standard practice: A systematic review and meta-analysis. Clinical Rehabilitation
Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Manual Therapy
Monaghesh, E., & Hajizadeh, A. (2020). The role of telehealth during COVID-19 outbreak: A systematic review based on current evidence. BMC Public Health
National Consortium of Telehealth Resource Centers. (2025). The telehealth policy cliff: Preparing for October 1, 2025.
Author:
Angela Rivera is a health writer who specializes in addiction care, telehealth, and behavioral science. With a background in patient education and evidence based communication, they focus on making complex clinical topics clear and approachable. Their work highlights practical strategies people can use to navigate recovery with confidence and support.
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