12 Chapter 1 Strategies to improve adherence Strategies to improve patients’ adherence include physiotherapist support, limiting the exercise regimen to two to four key exercises, enhancing patient self-motivation and self-efficacy (29), improving physiotherapist communication skills (30), and using behavioral change techniques (31). However, while evidence on these strategies’ shortterm effectiveness is mixed, they appear ineffective for long-term adherence (32). Digital health technologies, designed to aid clinicians and patients, offer a potential solution (33,34). The use of digital health technologies such as apps or web-based platforms during treatment has shown promising results. For example, studies found that online apps with personalized exercises, video guides, and exercise reminders enhance HBE adherence, exercise quality, and therapist-patient interactions (35,36). For example, an app developed to provide patients with the HBE recommendations from their physiotherapist on their smartphone combined with remote support resulted in higher adherence compared to paper handouts alone (35). Smartphone apps can aid in patient self-management and adherence to HBE by incorporating persuasive design elements (33,36–38). Persuasive design seeks to motivate users towards a desired behavior, either short-term or continuously (39). Persuasively designed apps use personalized feedback based on performance, reward systems, and reminders to engage patients actively (33,40). Incorporating self-management tips from credible sources like physiotherapists, other patients, or public figures can further motivate patients to follow the app’s guidance (33,41). Another advantage of the app lies in its constant availability, unlike the limited number and duration of face-to-face sessions with a physiotherapist. In a study investigating an app to support treatment of patients with osteoarthritis combined with face-to-face physiotherapy, patients indicated it improved treatment adherence and continuity between physiotherapist sessions (42,43). Despite the apparent advantages of the integration of the app in usual care, the acceptability, satisfaction, and performance of such technologies from the patient’s perspective are not well-understood and require further investigation. Development of e-Exercise LBP The e-Exercise LBP intervention was designed to enhance both the effectiveness and patient adherence to physiotherapy for patients with LBP. The intervention was developed through a multiphase, iterative process based on the Center for eHealth Research (CeHRes) Roadmap principles (44). This intervention adapts the existing e-Exercise program for patients with hip/knee osteoarthritis (e-Exercise OA), improving physical function, pain, tiredness, quality of life, and self-efficacy (42,45,46). Patients’ positive responses and high engagement with e-Exercise OA’s online component, coupled with physiotherapists’ feedback, shaped the e-Exercise LBP’s development (43,47). Additionally, persuasive design elements (personalization, motivation,
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