115 The short-term effectiveness of e-Exercise low back pain – a cluster RCT patients might have received stratified blended physiotherapy without being suitable for it; for example, a lack of motivation or digital literacy skills. Consequently, this could have resulted in the suboptimal effectiveness of our stratified blended physiotherapy intervention when compared with face-to-face physiotherapy. For future studies on blended care, it is recommended to use patients’ suitability for blended care as inclusion criteria or criteria to match treatment. The Dutch Blended Physiotherapy Checklist (58) could be a useful aid in this process. A third explanation might be the relatively high proportion of patients with a low risk of developing persistent LBP in this study. For this group, earlier research has shown that providing advice as a single intervention is likely to reassure the patient with LBP but does not result in different management of pain and disability in the short term (54,59). In addition, for this group, a stratified approach is beneficial from an economic perspective rather than in terms of clinical outcomes, as many of these patients recover completely within 2 to 3 weeks but nevertheless receive unnecessary treatment (57,60,61). A final explanation is the timing of our follow-up measurement at 3 months only. Given the favorable course of LBP (62) and the rationale that stratified blended physiotherapy will stimulate patients’ self-management and adherence (21,22), patients in the stratified blended physiotherapy group might recover faster, which is not captured by a single follow-up measurement at 3 months. Therefore, for future studies that aim to investigate postintervention effectiveness, it is recommended to measure the clinical outcomes immediately after the intervention is completed and to monitor the time to recovery. Strengths and Limitations This study had several important strengths. It is the next step in a multiphase development and implementation process based on the Center for eHealth Research Roadmap (63). After developing a prototype and testing its feasibility in a pilot study (23), this study determined the short-term effectiveness of the final stratified blended physiotherapy protocol and showed its potential compared with face-to-face physiotherapy. The pragmatic, multicenter, cluster randomized controlled trial design allowed for the evaluation of stratified, blended physiotherapy in comparison with face-to-face physiotherapy in a real-world situation. The baseline characteristics of both treatment groups and the distribution of the different prognostic risk groups of developing persistent LBP reflect the characteristics of patients with LBP normally being treated in primary care physiotherapy (60), which enhances the generalizability of our results. The use of measurement instruments recommended in the core outcome set for research into patients with nonspecific LBP (28) and a low dropout rate (10.1%) guaranteed the internal validity of the results. 5
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