166 Chapter 8 DISCUSSION In this thesis, we primarily explored the role of adherence to home-based exercise (HBE) programs in the treatment of low back pain (LBP), with a particular focus on the usage of an app to improve adherence and outcomes. Physiotherapists coached their patients on adherence to exercise behavior, utilizing the data provided by the patients through the platform. They used the app to deliver tailored information and HBE programs, as well as to monitor patient adherence. Furthermore, we detailed the development and validation of an instrument designed to measure adherence and examined patient views on utilizing a smartphone app to support HBE as part of their treatment. We also explored the relationship between adherence to HBE recommendations, variations in adherence throughout the treatment, and recovery from LBP. Additionally, we investigated the costeffectiveness of a stratified blended physiotherapy intervention. In this comprehensive discussion section, we will examine our principal findings, consider methodological aspects, and discuss future implications for clinical practice and research, particularly concerning patient adherence to HBE recommendations. For an in-depth analysis and discussion of the cost-effectiveness of the e-Exercise LBP intervention in managing LBP, we direct interested readers to the dissertation by Koppenaal (1). Key findings Chapter 2 details the development and validation of the Exercise Adherence Scale (EXAS) for patients with LBP, which measures adherence to HBE programs regarding frequency, intensity, and quality of performance recommendations. It demonstrated good construct validity and excellent intra-rater reliability, thereby demonstrating its suitability for the study of adherence in the e-Exercise LBP trial. In chapter 3 we investigated patients’ views on using a smartphone app to support HBE during physiotherapy for LBP, revealing that patients accepted and valued the app for its ease of use and support in exercise adherence, while also emphasizing the vital role of physiotherapists in guiding its optimal use. In chapter 6 we analyzed adherence patterns in patients with LBP, identifying three distinct trajectories: declining, stable, and increasing adherence. None of the baseline characteristics were associated with these trajectories, emphasizing the need for physiotherapists to continuously monitor and support adherence during treatment. Building on this, chapter 7 explores the link between adherence to HBE and clinical outcomes in patients with LBP, but we found no significant associations between adherence and changes in physical functioning or pain intensity, and recovery from LBP. This indicates a more complex relationship between HBE adherence and recovery from LBP than previously assumed. Regarding the stratified blended physiotherapy intervention, chapter 4 outlines a cluster randomized controlled trial protocol to evaluate the effectiveness and cost-effectiveness of the e-Exercise LBP intervention. E-Exercise
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