114 Chapter 5 important between-group differences in these outcomes, we consider the between-group differences as small. The difference in adherence might be explained by the benefits of integrating a smartphone app. The 24/7 availability of the app and functionality to remind the patient to perform scheduled exercises might have stimulated the patients to adhere to their prescribed home exercises in a better way than in the face-to-face physiotherapy group (18,53). Further research on the long-term clinical relevance of adherence to home exercises as prescribed in e-Exercise LBP is ongoing. The reduction of fear-avoidance beliefs complements evidence from a systematic review and meta-analysis that concluded that patient education provides reassurance for patients with acute or subacute LBP (54). In our study, this reduction in the stratified blended physiotherapy group might be explained by the information module of the smartphone app. As the information module provides the patient with self-management information about LBP, the patient can reread the advice and reassurance given in the face-to-face sessions by the physiotherapist about their LBP at all times. As a result, the harmless and nonspecific nature of LBP is possibly remembered in a better way (55). Long-term results should indicate whether this reduction in fear-avoidance beliefs also influences physical functioning, the handling of recurrent complaints, and costs a patient incurs because of LBP. Several explanations are possible to clarify why the additional benefits of stratified blended physiotherapy were not found. A first explanation is that the added value of a stratified approach in itself must be critically evaluated. Although clinical practice guidelines have adopted and advocated a stratified care approach for several years to improve patient outcomes, the added value of this approach is, at present, unclear. On the basis of previous recommendations, we decided to use the Keele STarT Back Screening Tool to create a matched web-based application (10). Our results show that, after specific training, treatment intensity (i.e., the number of face-to-face sessions) in the e-Exercise LBP group was in line with the patient’s risk profile, which was not the case in our control group. However, this difference in treatment intensity did not lead to relevant between-group differences. This seems to be in line with more recent studies evaluating the stratified approach according to the Keele STarT Back Screening Tool. The results from these studies are not convincing regarding the added value of such a stratified approach (56,57). Future research should focus on determining whether this concerns the added value of the tool itself or the added value of a stratified care approach in general. In addition, stratified blended physiotherapy might not be suitable for every patient. Earlier research has shown that it is difficult to determine what works best for each individual patient (22,50). In our study, we did not take into account the patient’s suitability for blended care to determine the optimal personalized blended treatment (58). As a result,
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