Why training and rehab consistency breaks down

Two patients. Same injury, same protocol, same encouraging send-off at the door. Eight weeks later one of them is back to normal and still doing the exercises nobody is checking up on. The other one quietly stopped around week three, and is back at the start with more frustration in the room than the first time.

The easy explanation is discipline. One of them had it, the other did not. Convenient, and almost entirely wrong.

Ask Linda Criens-Poublon what the hardest part of running a physiotherapy practice in Curacao is, and she does not say diagnosis. She does not say picking the right exercise. She says training consistency. Getting someone to keep doing the thing that is already working.

Here is why she is worth listening to on this. Most people her age have made a quiet peace with the idea that competitive sport is behind them. Linda walked onto a CrossFit floor again this year, at 70+, and finished:

• 1st in Curacao
• 1st at her own affiliate
• 7th in Europe
• 57th in the world

Every year since 2018, aging up through the divisions as she went, 60+, then 65+, now 70+, always near the top of whatever bracket she landed in. Her own explanation, written on her competitor profile: "I am a Physical Therapist and have enjoyed CrossFit since August 2016. The Open seems like a good personal challenge."

Enjoyed. A good personal challenge. Nobody prescribed it. Hold onto that sentence, because it turns out to be the whole ballgame.

First I was the patient

Long before any of this was professional, Linda was my physiotherapist and I was the one limping into her clinic. Contact sports will do that. I was a regular, not a drop in.

I would arrive genuinely wrecked and leave a single session noticeably better, maybe a third of the way back to normal. Her hands were not gentle about it. She was chasing the result rather than my comfort, and if the road there hurt, then it hurt.

I went back anyway, every time. Nobody was making me. I was a practicing doctor myself by then, a general practitioner, years before I specialized into internal medicine and endocrinology. I went back because the results were undeniable and I wanted them more than I wanted a pleasant hour.

That distinction, between doing something because you are told to and doing it because you can feel it working, turns out to be the entire subject of this article.

Then the relationship changed shape. The conversation stopped being only about my shoulder and started drifting toward the cases neither of us could crack alone. She would describe how a patient was moving, a compensation pattern, a joint that refused to settle. I would be thinking out loud about what might be running underneath it hormonally or metabolically, the kind of thing no movement assessment will ever surface.

She sees what I miss from a consultation room. I see what she misses from a treatment table. Put both views on one difficult patient and they get something neither of us offers alone. That is honestly all this series is: two people who have been doing this informally for years, finally writing it down.

It is not how motivated you are, it is why

A study published this year in BMC Public Health by Claes and colleagues took 335 adults and did something clever. Instead of sorting them by how much they exercised, it sorted them by why they exercised. Two kinds, drawn from a framework called Self Determination Theory:

• Autonomous motivation. You train because you enjoy it, or because it genuinely matters to you. Linda's "good personal challenge."
• Controlled motivation. You train because you feel you have to. Guilt, obligation, pressure, the voice telling you that you are being lazy.

Nobody is purely one or the other, and that is exactly the point. Four distinct groups appeared in the data.

The part that surprised us

The group high in autonomous motivation and low in controlled motivation came out best: more physical activity, better mood, better self rated health, lower BMI. No surprise.

Here is the surprise. The group scoring high on both, people who honestly enjoyed exercise but also felt pressured into it, did clearly worse on mood and on self rated health. And they were not moving less. They were moving slightly more than the group that felt better.

You can love the idea of getting strong again and still lose much of the benefit if part of the engine is shame about missed sessions. Notice what barely separated these groups: how much they trained. The reason did nearly all the work.

Three levers

The study points at a mechanism, and it happens to describe good physiotherapy almost exactly, whether or not anyone ever named it. Autonomous motivation grows when three things are satisfied:

• Autonomy. Real ownership of the plan, rather than a printed sheet handed down.
• Competence. Watching yourself get measurably better, rather than being told you are doing great.
• Relatedness. Feeling supported by someone, rather than processed by someone.

Pull none of those and "do your exercises because I said so" produces exactly the kind of motivation that works against you. It might buy two weeks. It rarely survives to week eight.

What to actually do about it

Almost everyone starts rehab controlled motivated. A doctor told you to. Insurance wants proof. Fear is driving. That is not a failure, it is just a fragile foundation, and the work is shifting the weight onto something sturdier before the fear wears off and takes the habit with it.

• Name the goal yourself. "Back on the padel court by September" or "sleep a full night without the shoulder waking me" beats any protocol handed to you, because now the plan is yours.
• Insist on a number that moves. Range of motion. A load you could not shift three weeks ago. A sit to stand count. Encouragement is an opinion. A number is evidence, and it is the cheapest source of genuine motivation available.
• Take the relationship seriously. A working relationship with someone who knows your case is not a soft extra. It is often what keeps people showing up once the pain that first brought them in has faded.
• Drop the guilt. "I should have done my exercises" is controlled motivation in six words. It buys a week of compliance and costs you the three months after it.

The takeaway

Recovery from an injury includes rehabilitation, and that phase has rules of its own. Reduce the training load while you are in it. Note the small improvements, because those are the evidence that it is working. Adhere to the rehab regime. Increase the load when it genuinely matches where the rehab process has actually reached, not when impatience says so. Stick to the program.

That is where this cuts both ways, and it is the trap at both ends. One person drifts off and quietly stops. The other feels good by week two and loads up early. Physiotherapists spend as much time holding back the eager as chasing the reluctant, and the eager ones are often the costlier mistake, because they earn themselves a setback and then lose faith in a program that was actually working.

Consistency was never a willpower problem, which is precisely why treating it as one keeps failing around week three.

You do not need to be a stricter version of yourself. You need to know why you are doing it at all, then build on the reasons that hold weight over time: enjoyment, ownership, visible progress.

Linda never needed the paper. She has been proving it on a competition floor every year since 2018, and she still shows up because she likes it. The rest of us finally have data that explains why that works.

Back to all writing