170 Chapter 8 be the core of patient motivation for adherence behavior. These perceptions reflect the constant weighing of the perceived necessity or expected costs and benefits of being adherent by the patient before deciding on their actual behavior. However, the impact of these components on adherence behaviors likely varies significantly among individuals, over time, and between treatments (19). For example, while reduced pain and disability following HBE might motivate one patient to continue their regimen, another patient might perceive the exercises as no longer necessary upon experiencing pain relief and opt to discontinue them. Similarly, increased pain could lead some patients to stop their HBE exercise program, while others might intensify their efforts in an attempt to increase the effectiveness of the HBE program. Furthermore, external factors such as social support, available time for HBE, or real-life events are often impossible to predict by both the patient and therapist, yet significantly impact adherence. Circumstances like illness, caring for a sick family member, workrelated events, and other similar occurrences can lead to temporary or more prolonged changes in a patient’s adherence behavior. These unaccounted factors and the individual variation in perceived costs and benefits of adherence might explain the lack of association between adherence and changes in physical function, pain, or recovery from LBP as discussed in chapter 7. Lastly, the role of physiotherapists in influencing patient perceptions of their treatment, including its benefits and costs, cannot be overstated. For example, if physiotherapists fail to effectively communicate the importance of exercise in recovering from LBP (resulting in patients perceiving the benefits as minimal) or if they recommend an impractical HBE regimen (making perceived costs high), patients are less likely to exhibit the expected adherence behavior. Thus, it seems essential that the approach to encouraging adherence is personalized, taking into account each patient’s unique perceptions, needs, and context. This requires physiotherapists to possess not only extensive knowledge on the clinical management of LBP, but also the communication skills necessary to adequately support their patients perceptions. Measuring adherence behavior needs further refinement The literature reveals that a diverse range of approaches is employed to measure adherence, including methods such as questionnaires, diaries, tally counters, and tracking the number of visits to the practice. However, many of these methods lack robust psychometric testing and/or suffer from poor conceptual foundations (20–22). The majority of these instruments are unidimensional, focusing solely on one aspect of adherence such as for example the number of completed exercise sessions, or they lack detail, measuring only frequency and intensity of patients’ adherence behavior. A combination of different components for measuring adherence, such as therapist
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