13 General introduction triggers, and conditioning) were implemented in the design of the e-Exercise app to facilitate and support behavior change in patients, and increase adherence to exercise recommendations from the physiotherapist. In total, fourteen different behavioral change techniques (such as goal setting, self-monitoring, shaping knowledge, tailored feedback, and shaping knowledge) were included in the app. The first three steps of the CeHRes Roadmap, namely contextual inquiry, value specification, and design, were followed in the development of e-Exercise LBP (44). Subsequently, a multicenter feasibility study tested the prototype, confirming its potential in reducing disability and pain (48). Based on these results and end-user usability experiences, the e-Exercise LBP prototype was further refined in preparation for broader operationalization and evaluation. e-Exercise LBP The e-Exercise LBP intervention uses a stratified blended approach, merging an app with traditional face-to-face physiotherapy to enhance treatment adherence and effectiveness. Both the app and in-person treatments adhere to the LBP guidelines set by the Royal Dutch Society for Physiotherapy (49). To improve the effectiveness and efficiency of physiotherapy care, treatment is stratified based on the patient’s risk of developing persistent LBP using the Keele STarT Back Screening Tool (50,51). The intervention’s duration, session count, and content are customized for three risk groups from the tool: low, medium, and high (52). The app features an information module with 12 weekly self-management themes, including assignments related to the etiology of LBP, physical activity, patient experiences, pain management, and psychosocial factors related to LBP. The app also includes an exercise module with a HBE program tailored to the patient’s prognostic risk profile, and a physical activity module containing a goal-oriented training program intended to help the patient maintain or improve their level of physical activity. App support duration varies by risk group for persistent complaints: three weeks for low risk, and twelve for medium and high risk (50). Patients can access the app content even after this period. The app’s content varies based on the patient’s risk level, with the physical activity module and graded activity functionality added for “medium” and “high risk” patients. The physiotherapist can monitor the patient’s use of the app, discuss assignments with the patient, and modify the HBE recommendations when needed. This enables personalized care adjustments to maintain patient adherence and optimize intervention results. Post-program, the app sends reminders every other week for six months to encourage ongoing adherence to a physically active lifestyle as recommended by the physiotherapist. Trajectories of adherence to HBE recommendations While the e-Exercise LBP program supports adherence, individual variations are likely due to numerous factors related to both patients and therapists (29,53–57). Additionally, 1
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