14 Chapter 1 adherence is also likely to vary over time during the treatment period among patients with LBP, resulting in distinct trajectories of adherence. While studies have yet to explore common adherence trajectories for patients with LBP, other patient groups have shown such patterns (58). Different trajectories imply varied clinical needs, and identifying a patient’s trajectory early can help clinicians tailor support and coaching to enhance adherence. Therefore, investigating the unique trajectories of adherence to HBE recommendations in patients with LBP has the potential to increase the effectiveness of interventions for this patient group. Adherence and outcomes Although it’s often thought that adhering to HBE directly impacts clinical outcomes, the link between adherence and LBP recovery may be more intricate, meriting deeper exploration. Only in more recent years have higher quality measurement instruments been published, allowing for more detailed and longitudinal measurement of adherence to HBE recommendations (22,59). Accordingly, this thesis concludes by examining how adherence to HBE influences LBP recovery in patients receiving physiotherapy. In summary, this thesis describes a comprehensive exploration of adherence to HBE programs during the treatment of LBP. A key focus is developing a new tool to measure HBE adherence, enabling the assessment of adherence and its impact on therapeutic results. The research examines patient views on digital tools supporting HBE in physiotherapy and evaluates the clinical effectiveness, cost-effectiveness, and impact on adherence rates of the e-Exercise LBP intervention for patients with LBP. Finally, the thesis aims to identify distinct trajectories of adherence to HBE recommendations and examine the associations between adherence and recovery from LBP. Through these analyses, the thesis aims to offer new insights to healthcare professionals, potentially enhancing LBP management with a deeper understanding of adherence to HBE and its links to recovery. The thesis focusses on adherence to HBE recommendations and is part of the e-Exercise LBP trial. For a more comprehensive evaluation of the (cost-)effectiveness of the e-Exercise LBP trial, interested readers are referred to the thesis “e-Exercise Low Back Pain: Stratified blended physiotherapy for patients with nonspecific low back pain” (60). Outline of the thesis Chapter 2 delves into the development and validation of the Exercise Adherence Scale (EXAS), an instrument specifically designed to measure adherence to HBE programs recommended by physiotherapists. This chapter provides a foundation for the subsequent investigations by establishing a reliable tool for quantifying adherence. Chapter 3 presents a qualitative study to understand patient perspectives on the acceptability, satisfaction, and performance of an app designed to support home-based
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