172 Chapter 8 whether modifying the EXAS is the most effective strategy or if developing a new measurement tool would be preferable. Lastly, creating uniform standards for interpreting adherence measurements is paramount and represents a crucial next step. The current diversity in measurement tools, scales, and scores (20,21) makes it challenging to clearly define what constitutes high or low, or when adherence is sufficient. Specifically for the EXAS, setting a threshold for adherence leads to an arbitrary judgment value, which could result in two patients with only minor differences in their adherence scores being classified differently, one as adherent and the other not. Improving adherence behavior of patients with LBP using e-Exercise LBP Evaluating e-Exercise LBP in relation to adherence During the development of the e-Exercise LBP intervention, one of our objectives was to create a tool that facilitates personalized care to support and maintain patient adherence during and after treatment (26). Drawing from experiences with e-Exercise Osteoarthritis, we integrated various behavioral change techniques (BCT’s) and persuasive design elements into the intervention (27–29). For example, to support and enhance the understanding and execution of the HBE regimen, the app complements the physiotherapist’s instructions and practical sessions with video and written instructions for the exercises. In doing so, we aimed to minimize patients’ uncertainty and doubts about how to perform the exercises correctly. Additionally, the physiotherapist sets exercise goals together with the patient, and the app supports these goals through customizable reminders and feedback through push notifications and messages. The pilot test of the intervention with patients with LBP indicated positive results (27). Our expectations regarding the efficacy of the intervention for improving adherence behavior were further strengthened by a review showing that interventions that implemented BCT’s showed significantly higher adherence in the treatment group in patients with musculoskeletal complaints (30). More specifically, implementing social support, goal setting, instruction of behavior, demonstration of behavior, and behavior practice/rehearsal were most supported by the evidence. Despite the careful development of the e-Exercise LBP intervention, we observed no to minor effects of the intervention on the outcomes (31). Based on our experiences, we identified potential improvements for the intervention. Improvements for e-Exercise LBP There are several areas where the e-Exercise LBP program could be further improved. Firstly, the training provided to physiotherapists should be expanded to include more comprehensive theory on adherence concepts, the importance of understanding patient perceptions regarding costs and benefits of adhering to HBE recommendations and
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