129 Trajectories of Adherence to HBE recommendations among People With Low Back Pain participated in the study and recruited patients from July 2018 to December 2019. Practices were cluster-randomized to either the intervention group or usual care group. The patients included in the parent trial were treated as a single cohort of patients with LBP and treatment group allocation was included in the analyses as a baseline characteristic. The study was approved by the Medical Research Ethics Committee of the University Medical Center Utrecht, the Netherlands (ISRCTN 94074203). Participants Patients with LBP were recruited through the participating physical therapists. Prior to participating, written informed consent was obtained from all patients, and eligibility was checked by the researchers (R.A. or T.K.). A patient was eligible for participation when (1) the patient requested physical therapist treatment for LBP (pain in the lumbosacral region sometimes associated with radiating pain to the buttock or leg) (21,22), (2) aged 18 years or older, (3) in possession of a smartphone or tablet with internet access, (4) B1-level proficiency in the Dutch language (23). Patients were excluded when patients had: (1) a specific cause of LBP determined through medical imaging or diagnosed by a medical doctor (including pelvic girdle pain caused by current pregnancy), or (2) serious comorbidities. When inclusion for the trial ended, a total of 208 patients enrolled in the study. Treatment All patients received treatment based on the clinical guideline for LBP from The Royal Dutch Society for Physiotherapy (22). The guideline recommends giving information and advice about the nature and diagnosis of LBP, the course and prognosis of LBP, and inhibiting and facilitating factors. Furthermore, the guideline recommends providing personalized exercise therapy, and behavior-oriented and hands-on treatments for specific patients. Patients in the intervention group received stratified blended physical therapy, consisting of usual care face-to-face physical therapy with integrated support from a smartphone application (e-Exercise LBP) (13,24). The content of the e-Exercise LBP app was also based on the clinical guideline for LBP from The Royal Dutch Society for Physiotherapy (22). The content of the e-Exercise application was tailored to the needs of the patient by the physical therapist and contained texts and videos with selfmanagement information, the HBE exercises recommended by the physical therapist, and a mod- ule to support the patient’s physical activity. Each patient received treatment exclusively from the same physical therapist, maintaining consistent therapeutic interactions between patients and their respective physical therapists throughout the study duration. The evaluation of the effectiveness of the e-Exercise LBP intervention in patients with LBP showed no significant between-group differences after 3 months for almost all outcomes (25). Only fear-avoidance beliefs and self- reported adherence 6
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