Patient Retention in Physiotherapy: Why Patients Drop Out

Patients leave a physiotherapy plan of care early for a small set of reasons that come up again and again. They are getting better fast enough, getting to the clinic is hard, they do not see what more sessions will add, they need a different kind of care, or the relationship with the therapist is not working. To improve patient retention in physiotherapy, agree a plan at the first visit that the patient understands and can fit into their life, keep the gaps between visits short, send reminders, act on the very first missed visit, and plan the discharge rather than letting it happen by default.

Retention here does not mean keeping people coming for as long as possible. It means patients finishing the plan you agreed together, or leaving it for a good reason that you both know about. A patient who is better after three visits and walks out with a self-management plan is a success. The patient this guide is about is the one who quietly stops after the first visit, still in pain and unsure what to do next.

If your problem is patients who turn up but skip their exercises at home, read why patients don't do their home exercises and how to write a home exercise program. This guide is about attendance and dropping out of the plan itself.

How common is dropout from physiotherapy?

Common enough that every clinic sees it. The figures vary a lot, though, depending on the setting and on what counts as a dropout.

The largest dataset comes from Bhavsar and colleagues, who looked at 444,995 patients treated for musculoskeletal conditions across 697 clinics run by one US physical therapy company. Of those patients, 73% had at least one missed visit during an episode of care. The authors counted a visit as missed whenever it ended as canceled or pending rather than completed, so that figure includes cancellations as well as people who failed to turn up.

Smaller studies measure different things. In a chart review of 200 people with chronic pain, Balinski and colleagues reported an attendance rate of 73% and a self-discharge rate of 55%. Leatherwood and colleagues phoned 100 patients six weeks after an orthopedic clinic had prescribed physical therapy, and 40 of them had not attended a single session. The systematic review by Jack and colleagues cites an earlier study in which 14% of physiotherapy patients did not come back for their follow-up appointments.

Several of these studies come from US clinics, where insurance shapes attendance in ways that may not apply to you. Use the numbers as a reason to measure your own clinic, not as a benchmark to compare against.

Why do patients drop out of physiotherapy?

The most direct answer comes from asking the patients who left. Thomas and colleagues interviewed 26 people who had a physical therapy evaluation for a musculoskeletal problem, did not return within 30 days, and had nothing else booked. Their reasons fell into five groups:

Access issues: 7 of the 26.
They were improving at a rate they were happy with: 6.
They did not see the value, or felt they could do the therapy on their own: 6.
They needed other medical care: 4.
Problems in the relationship with the physical therapist: 3.

It is a small study, and one health system. Look at that list: very little of it is about laziness. Most of it comes down to access, expectations or communication, and a clinic can do something about each of those.

The Leatherwood survey points the same way. Of the 40 patients who never started, the most common reasons were lack of time (14 people) and choosing to do their own therapy at home (11). Insurance (3) and transport (2) came up less often. Patients referred after surgery were more likely to attend than those referred for physical therapy as their main treatment. The authors suggest that the second group may benefit from a fuller discussion with their doctor about what physical therapy can offer.

What predicts a patient dropping out

Jack and colleagues reviewed 20 cohort studies from musculoskeletal outpatient physiotherapy, where adherence covered attending appointments as well as doing the exercises. They found strong evidence that poor adherence was linked with low physical activity before treatment, low self-efficacy (the patient's confidence that they can do what is asked), depression, anxiety, helplessness, poor social support, more perceived barriers to exercise, and pain that increased during exercise. They also pointed out that most research had looked at patient factors, and very little at what therapists or clinics do.

Your appointment book holds some warning signs too. In the Bhavsar data, more missed visits were linked with more previous cancellations, a longer time between booking and the appointment, and a longer gap since the last visit. Patients over 65 missed fewer visits than younger adults. In a trial by Taylor and colleagues, nonattendance was higher in younger patients, in people with neck or trunk problems or neuromuscular conditions, and for first appointments and appointments on a Monday or a Friday. Balinski and colleagues found that patients with more no-shows were more likely to discharge themselves.

These are associations, not causes. Even so, an early cancellation or no-show is one of the few warning signs you can see in your own records that a patient may be about to drop out.

What clinics can do to improve patient retention

Agree the plan at the first visit

Before the patient leaves the first session, they should be able to tell someone at home what is wrong, what the plan is, roughly how many visits it involves and over what time, and what should be different by the end. Six of the 26 patients in the Thomas study left because they did not see the value of carrying on or felt they could do it on their own. A plan they understand gives them a reason to come back, although no study has tested this step on its own.

Jack and colleagues conclude that physiotherapists should work with patients to design realistic treatment plans that fit their life circumstances. In practice, that means asking what might get in the way before you set the frequency. Shift work, a long commute, cost, a parent to look after: any of these can turn a twice-weekly plan into a plan the patient abandons in week two. Where the condition allows it, one visit a week that happens is better than two that do not.

Many physios write the goal down in the patient's own words, such as "walk to the temple without stopping" or "lift my daughter without back pain". Jack and colleagues suggest goal setting as one way that may build a patient's confidence, but their review looked at barriers, not at whether this works. A written goal gives you both something to check progress against, and it belongs in your notes. The SOAP notes guide covers where it goes.

Build the relationship on purpose

Hall and colleagues reviewed 13 studies on the working alliance, meaning the bond and the shared goals between therapist and patient, in physical rehabilitation. A stronger alliance was linked with better treatment adherence in people with brain injury and in a mixed group of physical therapy patients, with higher satisfaction in musculoskeletal patients, and with better physical function in older adults and people with chronic low back pain. The authors say more research is needed to know how strong the effect is.

Hush and colleagues, in a review of patient satisfaction with musculoskeletal physical therapy, found that satisfaction depended mainly on the therapist's interpersonal qualities and the process of care. Treatment outcome was only occasionally, and inconsistently, linked with satisfaction. Patients judge you on how you treat them at least as much as on whether the pain improves.

None of this needs a script. Listen to the whole story before you examine. Explain what you find as you go. Ask what the patient is worried about and answer it.

Many clinics also try to keep a patient with the same physio for the whole plan where they can. That is common practice rather than something the studies above tested, but relationship problems were behind 3 of the 26 dropouts in the Thomas study, and a relationship is hard to build with a different person each visit.

Book ahead and keep the gaps short

Many clinics book the next visit before the patient leaves the room. No trial has tested this, but it fits the Bhavsar data, where a longer time between booking and the appointment, and a longer gap between visits, were both linked with more missed visits.

That sits a little awkwardly with booking the whole plan in one go, because the later visits then have a long lead time. A common middle path is to book the next one or two visits at a time and confirm the rest as you go. If the plan does call for a longer gap, a short message in between keeps you in touch.

Send appointment reminders

Reminders have been tested in a randomized trial in physiotherapy clinics. Taylor and colleagues randomized 679 patients at two hospital physiotherapy outpatient departments. The no-show rate, meaning patients who neither came nor canceled, was 16% with no reminder and 11% with a text message reminder before the next appointment. That works out to one fewer no-show for about every 19 patients reminded, though the likely range around that figure was wide. Cancellation rates and overall attendance rates did not differ significantly between the groups.

A Cochrane review by Gurol-Urganci and colleagues, covering healthcare appointments in general, found that text message reminders improved attendance compared with no reminder and worked about as well as phone call reminders. In the two studies that looked at cost, a text reminder cost less per attended appointment than a phone call. The quality of evidence was low to moderate.

The trials tested text messages (SMS). If your patients mostly read another messaging app, the same idea applies, but it is not what these trials tested. Keep the reminder short, give the day, time and place, and make it easy to reply if they need to change the time.

Act on the first missed visit

Previous cancellations predicted later missed visits in the Bhavsar data, and more no-shows went with self-discharge in the Balinski study. So many clinics treat the first missed visit as the moment to act. That is common practice rather than a tested strategy.

Call or message the same day. Ask neutrally, without blame. Something like "We missed you today. Is everything all right, and would you like to book another time?" leaves room for the patient to tell you what is really going on.

Listen for the reason and match your response to it:

If it is timing or travel, offer another slot, a home visit or a video session where that suits the problem.
If they feel better, agree a shorter plan and a clear self-management program rather than losing touch.
If they feel it is not helping, offer a review session to reassess, change the plan, or refer them on if needed.
If they are unhappy with how they were treated, thank them for saying so and offer another physio if you have one.

If the patient says their symptoms are getting worse, or mentions new numbness, tingling or weakness, arrange a prompt reassessment or medical review, not just a new booking. Some signs need emergency care, not a booking: new bladder or bowel problems or numbness around the genitals or buttocks with back pain, chest pain, fainting, sudden breathlessness, sudden weakness or numbness on one side of the face or body, or trouble speaking. Tell the patient to call the local emergency number or go to an emergency department straight away. A painful, swollen calf, especially after surgery or a leg injury, needs a medical check the same day, and emergency help if breathlessness or chest pain comes with it.

Make it easier to attend

Access problems were the most common reason in the Thomas study, and lack of time was the most common reason in the Leatherwood survey. Early morning and evening slots, shorter follow-up sessions, home visits and video sessions can all make turning up easier. Apart from video, these are practical options, not tested ones.

Simmich and colleagues reviewed randomized trials comparing real-time video physiotherapy with in-person care. Across 8 trials, attendance averaged 8% higher with video, but the likely range ran from 1% lower to 18% higher, so video may do no better than in-person care. Satisfaction was similar. The certainty of that evidence was low to very low, and not every problem suits a video session, especially when you need your hands for the assessment. Offering video as an option for some follow-ups, rather than a replacement, is a reasonable middle path.

Keep the plan going between visits

Between visits, the home program is the patient's main contact with your plan. Keep it short, practice it in the room, and send it somewhere the patient will actually look; the two guides linked above cover how. If you use PocketPhysio, the program goes to the patient by link, SMS or email, in the Pocket Physio Care app or on WhatsApp. Every exercise has a video and a spoken voice guide, and when the patient comes back you can see what you gave them last time and progress it.

There is one catch. Some patients decide they can manage alone once they have a program at home. In the Thomas study, "could do the therapy on my own" shared a theme with "did not see the value", and together they covered 6 of the 26 patients. That is fine if it is the agreed plan. It is a problem if it happens before they are ready, so tell the patient what you still need to check in person and why.

Plan the discharge

Some dropouts are really unplanned discharges. In the Thomas study, 6 patients stopped because they were improving at a rate they were happy with, and 4 needed other medical care. Talk about discharge from the first visit: what "done" looks like, and what happens if they improve faster than expected. A patient who stops early with a self-management plan and an open invitation to call is in a very different place from one who simply disappears.

When a patient moves to other care, such as an injection or surgery, it is good practice to send a short note to the doctor and tell the patient they are welcome back for rehab afterwards.

What the evidence does not tell us

The research on improving attendance is thin. McLean and colleagues found only 5 suitable studies on strategies to improve adherence with outpatient musculoskeletal physiotherapy. There was moderate evidence that a motivational program based on cognitive behavioral principles improved attendance at exercise-based clinic sessions, conflicting evidence for short-term adherence with exercise, and strong evidence that adherence strategies did not improve long-term adherence with home exercise.

Of the steps in this guide, text reminders have the clearest trial evidence in physiotherapy clinics. Video sessions have been compared with in-person care in trials, but that evidence is low to very low certainty. The rest, such as agreeing the plan at the first visit, booking ahead, same-day calls after a missed visit, keeping the same physio, planning the discharge and tracking your numbers, are common practice built on the associations above, not on trials.

Most of the studies above came from hospital systems or large clinic groups, and payment systems differ a lot between countries. Treat these steps as a starting point, and check what works in your own clinic.

How to measure patient retention in your clinic

Count before you change anything. A simple monthly record is enough to start:

Visits attended as a share of visits booked.
No-shows and cancellations, counted separately. In the Taylor trial, reminders reduced no-shows but not cancellations.
Patients who stopped before the planned discharge.
The reason each of those patients stopped, if you know it. The five groups from the Thomas study make workable categories.
Patients discharged with their goals met.

Change one thing at a time, such as adding reminders or same-day calls after a missed visit, and compare the next few months with the last few. A small clinic will see noisy numbers month to month, so look at the trend rather than a single month.

A patient retention checklist

At the first visit, explain the findings, the plan, the rough number of visits and the goal in plain words.
Ask what might get in the way, and set a frequency the patient can keep.
Book the next visit before the patient leaves.
Send a reminder before each appointment.
Call or message the same day after any missed visit, and ask why.
Offer early, late, home or video options where they suit the problem.
Send the home program to the patient's phone.
Talk about discharge early, and plan it.
Track attendance, dropouts and the reasons every month.

Most of these steps need no extra staff. Pick the two or three that fit your clinic best, do them with every patient, and check your patient retention numbers again in three months.

References

Bhavsar NA, Doerfler SM, Giczewska A, Alhanti B, Lutz A, Thigpen CA, George SZ. Prevalence and predictors of no-shows to physical therapy for musculoskeletal conditions. PLoS One. 2021;16(5):e0251336. doi:10.1371/journal.pone.0251336
Balinski M, Blanchard L, Mendoza R, Zaranec M, Duncombe A, Madhavan S. Factors associated with physical therapy attendance rate and self-discharge in people with chronic pain. JOSPT Open. 2024;2(4):332-339. doi:10.2519/josptopen.2024.1136
Leatherwood W, Torres A, Hidalgo Perea S, Paulus M. Demographic and diagnostic factors in physical therapy attendance. Cureus. 2024;16(3):e55908. doi:10.7759/cureus.55908
Jack K, McLean SM, Moffett JK, Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual Therapy. 2010;15(3):220-228. doi:10.1016/j.math.2009.12.004
Thomas AC, Shaver SN, Young JL, Cook CE. Reasons for patient no-shows and drop-offs after initial evaluation in physical therapy outpatient care: a qualitative study. Musculoskeletal Science and Practice. 2025;77:103326. doi:10.1016/j.msksp.2025.103326
Hall AM, Ferreira PH, Maher CG, Latimer J, Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical Therapy. 2010;90(8):1099-1110. doi:10.2522/ptj.20090245
Hush JM, Cameron K, Mackey M. Patient satisfaction with musculoskeletal physical therapy care: a systematic review. Physical Therapy. 2011;91(1):25-36. doi:10.2522/ptj.20100061
Taylor NF, Bottrell J, Lawler K, Benjamin D. Mobile telephone short message service reminders can reduce nonattendance in physical therapy outpatient clinics: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2012;93(1):21-26. doi:10.1016/j.apmr.2011.08.007
Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database of Systematic Reviews. 2013;(12):CD007458. doi:10.1002/14651858.CD007458.pub3
Simmich J, Ross MH, Russell T. Real-time video telerehabilitation shows comparable satisfaction and similar or better attendance and adherence compared with in-person physiotherapy: a systematic review. Journal of Physiotherapy. 2024;70(3):181-192. doi:10.1016/j.jphys.2024.06.001
McLean SM, Burton M, Bradley L, Littlewood C. Interventions for enhancing adherence with physiotherapy: a systematic review. Manual Therapy. 2010;15(6):514-521. doi:10.1016/j.math.2010.05.012

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.