127 Trajectories of Adherence to HBE recommendations among People With Low Back Pain INTRODUCTION The impact of low back pain (LBP) on society and health care and its related cost is well established (1). For decades, exercise has been studied as a potential treatment for LBP, and as a result, exercise (e.g., strength training or mobility exercises) is part of the core recommendations for the treatment of LBP in many clinical guidelines (2–5). However, the heterogeneity of effects found between different studies, caused by factors such as differences in interventions, methodologies, and follow-up durations, makes it difficult to determine which exercise intervention is most effective for individual patients. Despite this, pooled data from 27 trials involving 3514 participants showed that exercise therapy reduces pain and functional limitations compared with non-exercise treatment in patients with persistent LBP (6). Furthermore, many interventions incorporate home-based exercise (HBE) to increase treatment effectiveness or as a solution to alleviate the burden of LBP on the public health system (7). However, the effectiveness of exercise interventions largely depends on adherence, and without supervision from a clinician, patient adherence to HBE recommendations is often low, reducing treatment effectiveness (8–10). The World Health Organization defined adherence as “the extent to which a person’s behavior – taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider” (11). Adherence to HBE recommendations would then be defined as “the extent to which a person’s behavior corresponds with agreed HBE recommendations from a health care provider.” Research has shown that adherence to exercise recommendations from a physical therapist is a complicated and multi- factorial construct, with factors such as social support, guidance by the therapist, the number of exercises, self-motivation, self-efficacy, and psychological aspects influencing individual patients’ adherence (10). To increase patient adherence to HBE recommendations, interventions targeting patient adherence were developed and showed varying levels of effectiveness. For instance, a trial investigating the effects of practitioner communication skills training on patients’ adherence to HBE recommendations in patients with chronic LBP found that adherence declined over time and the intervention appeared to only slow the rate of decline (12). In another study, using a smartphone application to support adherence to HBE recommendations increased self-reported adherence compared to usual care after 3 months (13). Unfortunately, the complexity of adherence to HBE recommendations makes it a challenging construct to measure resulting in a large number of different measurement instruments (14,15). Although many instruments aimed at measuring adherence to HBE recommendations are available, there is a lack of validated instruments making adherence difficult to study (14). To fill this gap, the recently developed Exercise Adherence Scale (EXAS) was designed to measure adherence to frequency, intensity, and quality of 6
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