Strong evidence that we can't fix home exercise adherence long-term. So what are you all doing?

Been chewing on this more than is probably healthy.

Went digging through the adherence literature after a stretch of patients turning up at week four having done basically nothing. Non-adherence with physio treatment and exercise gets estimated as high as 70%, and it's specifically worse for unsupervised home programmes. One low back pain study had only 35% highly adherent, with about half showing low or no adherence across the whole course. ScienceDirectnih

Fine. I knew it was bad. Here's the bit I wasn't ready for.

There's a systematic review of interventions designed to fix this. Moderate evidence that motivational CBT-style programmes improve attendance at clinic sessions. Strong evidence that adherence strategies don't improve long-term adherence with home exercise. PubMed

So the stuff we all default to, explaining the why, setting goals, printing a cleaner handout, has been tested and doesn't survive past the short term. Goal setting specifically showed no significant difference in Bassett and Petrie's work. nih

The only thing that's helped me is prescribing less. Three exercises they'll actually do beats eight they won't. But that's an n of one, and I honestly can't tell if I've found something or just lowered my expectations and called it a method.

Other thing I can't untangle: how much of the drop-off is people getting better and quietly discharging themselves. Which would be completely fine. I just have no way of separating them from the ones who stalled out.

Anyway. What actually works for you? Not what you were taught. What actually works.