Why Patients Skip Their HEP and How to Fix It

Every PT knows one universal truth.
The patients who actually do their home exercise program get better faster. The patients who don’t, well, they don’t. Obviously there are outliers both ways, but this shouldn’t be groundbreaking news.

Here’s the interesting part.
If we already know this, why isn’t this a bigger area of focus for rehab professionals? And why do so many patients still ignore their HEP?

Is it laziness?
Forgetfulness?
Lack of motivation?
Those explanations are convenient, but they don’t get to the root. The deeper issue is usually buy in.

And in amputee rehab, buy in is multiplied.
Everything we do in this specialty depends on repetition, pattern building, and motor learning. A patient with limb loss who never practices weight shifting, balance work, or works on that hip flexion contracture outside the clinic will progress far slower than someone who puts in the reps. Not because they’re less capable, but because these skills require exposure and consistency the clinic alone can’t provide.

Most HEP failures aren’t patient failures.
They’re communication failures.

And that’s where Extreme Ownership comes in.

One of the biggest lessons I learned from Jocko Willink’s book is this:
If something isn’t working, look at what YOU can change.
You can’t control the patient.
You can always control your approach.

Instead of saying, “They didn’t get better because they didn’t do their exercises,” try reframing it as,
“They didn’t do their exercises because something in my delivery didn’t land. What can I adjust?”

That shift alone changes everything.

Because here’s the truth.
You’re not selling them an exercise list.
You’re selling them an outcome.
Your rehab plan is the product.
Their buy in is the purchase.

And I’m not saying we need to turn PT into a used car lot.
But the business world understands something rehab often ignores.
People take action when the offer makes sense to them, when the steps feel doable, and when they feel understood.

So here are a few ideas that actually change HEP compliance, borrowed from sales psychology, behavior science, and a little Extreme Ownership.

Make the value obvious, not the task.
Patients don’t buy three exercises. They buy outcomes.
If they don’t clearly see how the exercise connects to the life they want back, they won’t do it.
Explain the outcome, not the mechanics.

Expose the pain point.
In sales, clarity drives action. People move when they understand the cost of doing nothing.
“If you want to get back to X, this is the exercise that gets you there. If it doesn’t happen at home, your progress slows down.”
You’re not creating fear. You’re giving them clarity.

Set a consequence, not a suggestion.
“Do this or don’t, but your progress will follow your consistency.”
Patients take ownership when the expectation is presented honestly.

Use micro contracts.
Ask: “How confident are you that you can do this three times before next session?”
If they say anything under a 7, ask: “What would make it a 9?”
Now they’re co-designing the plan instead of passively receiving it.

Build accountability into the plan.
Sales works because follow up exists. PT often forgets that piece.
A simple, “I’m going to ask about this first thing next session,” changes behavior fast.
The nuclear option: “Record yourself doing it twice this week and show me the video.”
Compliance skyrockets when patients know there’s accountability.

Remove friction.
People don’t avoid hard things. They avoid inconvenient things.
Tie the HEP to something they already do:
“Do this right after your coffee.”
“Do one round before bed.”
Make the first rep the win, not the whole workout.

These are the levers that move behavior.
Not the length of the exercise list.
Not a perfect explanation.
Not hoping they’ll magically comply.

And here’s another important point.
What works for one patient won’t work for another. Some respond to structure. Some respond to humor. Some respond to fear reduction. Some respond to competition. Some need clarity. Some need repetition. You have to understand the person in front of you, and find out what makes them tick.

This is especially true in amputee rehab.
You’re not just coaching exercises. You’re coaching confidence, trust, and movement built on a brand new foundation. The psychology matters just as much as the biomechanics.

When you start viewing HEP compliance through this lens, the whole game changes. It stops being a mystery and becomes a skill you can improve.

Your exercises don’t need to be fancy.
Your psychology does.
Especially in amputee rehab, where carryover outside the clinic is what truly builds independence.

That’s where real outcomes come from.