141 Trajectories of Adherence to HBE recommendations among People With Low Back Pain of the estimated parameters and estimated variance. The last limitation of the study is the higher proportion of patients with a duration of the current episode of LBP of less than 12 weeks is greater than the proportion of patients with a longer duration of LBP at the start of the study. This difference in proportions might make it difficult to generalize the current findings to patients with chronic LBP. However, the proportions of patients with a duration of the current episode of more than 12 weeks are roughly similar between all 3 trajectory classes at 38.1, 46.1, and 41.9%, respectively. Furthermore, these proportions are again roughly similar to the proportion of 43.4% of patients with a duration of the current episode of more than 12 weeks in the entire sample. Therefore, it appears that the results from the current study can be reasonably well generalized to patients with LBP of all durations. Although no differences between baseline characteristics of the identified trajectory groups were found, the results show that there is no single trajectory of adherence for all patients and that it might not be possible to distinguish different subgroups based on baseline characteristics alone. Therefore, when planning patient treatment, clinicians should not attempt to determine adherence of their patients at the start of treatment and base interventions on that assessment. Instead, monitoring adherence during treatment using an instrument such as the EXAS and intervening when adherence is too low appears to be the optimal strategy. Future research should incorporate the patient–therapist interaction, the patient’s social environment, and patient characteristics when studying patient adherence to better under- stand how patient adherence can be supported during physical therapist treatment. Another important next step in the research on patient adherence in patients with LBP is to study the association between trajectories of adherence to HBE and clinical outcomes to assess the effects of adherence on clinical outcomes. Conclusion Three different trajectories of adherence to HBE recommendations were identified in patients with LBP. No differences in baseline characteristics were found between the 3 trajectory groups; therefore, physical therapists should not attempt to place a patient in a trajectory group at the start of treatment. Instead, adherence should be closely monitored as treatment progresses and supported when required. Author Contributions Concept/idea/research design: R. Arensman, C.J.J. Kloek, R.W.J.G. Ostelo, C. Veenhof, T. Koppenaal, M.F. Pisters Writing: R. Arensman, M.W. Heymans, C.J.J. Kloek Data collection: R. Arensman, T. Koppenaal 6
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