167 General discussion LBP is a blended approach combining a smartphone app with traditional face-to-face physiotherapy, aimed at enhancing adherence to HBE, self-management skills, and physical activity in patients with LBP. Finally, chapter 5 shows that while the e-Exercise LBP intervention did not surpass usual face-to-face physiotherapy in enhancing physical functioning overall, it was effective in reducing fear-avoidance beliefs and increasing selfreported adherence to HBE recommendations, particularly benefitting high-risk patients with persistent LBP. Our approach to understanding adherence to HBE recommendations posits that adherence is essential for evaluating the effectiveness of new treatment strategies. This is because if participants do not adhere to the minimal required treatment dose for a given intervention, determining the intervention’s success is impossible. We also presuppose that clinicians design HBE regimens based on exercise physiology and sports science principles to maximize treatment outcomes. Therefore, to effectively assess the optimal content of exercise interventions and their impact on clinical outcomes for patients with LBP in research and clinical practice, comprehending and accurately measuring patients’ adherence behavior is a crucial first step. To this end, three main themes will be discussed. First, our findings warrant reconsidering our perspectives on the construct of adherence to HBE recommendations. Second, the measurement of adherence to HBE recommendations needs further refinement to improve the accuracy of data available for researchers and clinicians. Lastly, optimizations for the e-Exercise LBP program or novel interventions to improve adherence behavior of patients with LBP need to be identified to improve patient adherence in clinical practice. Perspectives on adherence to HBE recommendations Previous research on adherence to HBE recommendations in patients with LBP has identified several predictors of adherence. These include patient-related factors like self-efficacy and educational background, aspects specific to the treatment such as its type and setting, therapist-related elements including perceived support and coaching style, environmental factors like the distance to the practice and financial considerations, as well as social influences, for instance, support from peers (2–9). Despite including a number of these factors in our analyses, we did not find any factors related to the membership of a trajectory adherence class (chapter 6). This was unexpected, given the apparent theoretical basis for the factors that were included. Furthermore, the existing literature on LBP indicates ambiguous or limited support for the effectiveness of exercise in diminishing pain and disability (10,11), yet studies also often report low adherence or provide no information on adherence to exercise interventions (11,12). Therefore, our initial assumption was that the disappointing effectiveness of exercise interventions could be explained by variable patient adherence and that the 8
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