173 General discussion enhanced communication skills (32). This knowledge is crucial for understanding and addressing the perceived and practical barriers that patients might face with adherence to HBE. Furthermore, the same skills and knowledge can be used by the physiotherapist to tailor not only treatment, but also the mode of delivery of the treatment to each individual patient’s needs. Using the e-Exercise LBP app itself might not be the optimal solution for every patient. Some patients might prefer paper handouts of the information and exercises provided through the app or prefer using a website instead. To this end, another improvement could involve utilizing tools such as the Dutch Blended Physiotherapy Checklist (18) to screen patients for their suitability for blended care interventions, ensuring that each patient receives the most appropriate form of intervention. Another improvement would be to incorporate statistics on app use by the patient in the online dashboard of the physiotherapist to allow the therapist to coach the patient in its use. Similar to HBE, the effectiveness of the e-Exercise LBP app depends on patient adherence and improving use of the app by patients might be an opportunity for improvement. Lastly, a consideration should be made regarding which patients are most likely to benefit from the intervention or specific parts of the intervention (17). In the current design of the e-Exercise LBP intervention, the content of the app is based on the patient’s risk for chronic complaints (26), which means that adherent patients receive the same support as nonadherent patients. Reducing support through the app in adherent patients and increasing support for non-adherent patients could result in more effective use of resources. Future directions Research methodologies to study exercise adherence To increase our understanding of adherence among patients with LBP, it is crucial to adopt research designs that can accommodate the wide range of individual differences among patients, as well as variations in the length, composition, and setting of treatments. The RCT design has received criticism as the golden standard for the design of intervention studies for physiotherapy (33). While RCTs are appropriate for identifying the average effects of treatments across populations, applying these results to individual cases in clinical practice is challenging, including for individuals who participated in the trial (33). An RCT provides the average effect of a treatment across a group, but this average does not guarantee the same level of effectiveness for each individual receiving the treatment. This suggests that if a RCT shows an effect size close to zero, the treatment being studied may be considered ineffective overall. Instead, it could also imply that the individuals who actually experienced benefits from the intervention might not have been adequately represented in the trial. 8
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