112 Chapter 5 DISCUSSION Principal Findings This study evaluated the short-term (3 months) effectiveness of the stratified blended physiotherapy intervention e-Exercise LBP on physical functioning in comparison with face-to-face physiotherapy in patients with nonspecific LBP. In contrast to our expectations, the study results showed no statistically significant between-group difference in physical functioning and most of the secondary outcome measures. Only fear-avoidance beliefs and patient self-reported adherence to prescribed home exercises improved significantly in patients who were allocated to stratified blended physiotherapy. When looking at the different prognostic risk groups in patients with a high risk of developing persistent LBP, a statistically significant between-group difference in favor of stratified blended physiotherapy on physical functioning, average pain intensity, and fear-avoidance beliefs was found; however, these results come with some uncertainty. Interpretation of the Findings The results of this study complement the findings from previous systematic reviews of randomized controlled trials that showed that in the short term, web-based applications could reduce LBP-related pain and disability; however, when compared with other interventions, the results are inconclusive (15,22,50). A possible explanation for these inconclusive findings is the considerable heterogeneity in the studied characteristics and comparators, which hampers a clear comparison. For example, in our study, we integrated a web-based application within face-to-face guidance and compared it with face-to-face physiotherapy. Previous studies in this research area have focused predominantly on web-based applications as a stand-alone intervention without the face-to-face guidance of a health care professional (15,22,50). Only a few studies have investigated web-based applications as an adjunct to face-to-face guidance, and the results regarding the added value of these combined interventions have been inconclusive (15,51). Similar to our study, Sandal et al (51) investigated a smartphone app as an adjunct to face-to-face guidance. The app was tailored using artificial intelligence and did not influence face-to-face guidance. In this study, the reported between-group difference was statistically significant in favor of the combined intervention when compared with face-to-face guidance alone; however, the difference was small and of uncertain clinical significance. Another example of heterogeneity in research on web-based applications is the large variation in delivery modes and duration. Similar to e-Exercise LBP, most web-based applications tailored the content of the intervention using patient characteristics and focused on self-management support, home-based exercise, and physical activity prescription (15,22,50). However, the e-Exercise LBP app provided this content in
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