175 General discussion multiple-baseline design appears to be the most suited for physiotherapy research, due to its stronger internal validity, and its ability to adjust for unknown effect duration and carry-over times of treatments (36). This is especially important when a washout effect of the intervention is undesirable, for instance when studying interventions designed to reduce pain or disability in patients. Limitations of the design are that missing data can be problematic and attrition can threaten interpretation of the results. Furthermore, the multiple-baseline design requires three to five participants to start the study concurrently, which can be a logistical issue (36). Similarly to the ITS design, the proper use of research methods and statistical analysis can be challenging due to the unfamiliarity of researchers with these designs. However, using the Single-Case Reporting Guideline in Behavioral Interventions (SCRIBE) Checklist provides a way to standardize the design, analysis, and reporting of multiple-baseline design studies (37). Technology to improve and support adherence in clinical practice In addition to refining existing interventions and methodological approaches in research and clinical practice, new technological advances such as gamification or generative artificial intelligence (AI) might offer substantial benefits in improving adherence to HBE recommendations. Gamification, which is the incorporation of gaming elements in a non-gaming environment, has already shown promise in musculoskeletal rehabilitation and LBP by improving motivation and exercise adherence (38). Similarly, an AI-assisted interactive health promotion system has demonstrated effectiveness in managing neck/ shoulder stiffness/pain and low back pain (39). However, the use of AI in healthcare is only a recent development and new ways to leverage its advantages are discovered daily (40). For instance, generative AI might assist patients with instant responses to any questions or concerns they might have by being able to chat with AI bots specifically trained on guidelines and other verified sources of information. Another possibility could be that patients can ask a generative AI to provide alternatives for exercises or receive real-time feedback and encouragement when exercising, such as using the TRAK© telerehabilitation tool (41). These possibilities indicate a future where generative AI and other technologies could significantly transform physiotherapy treatments and the support tools available for patients with LBP. Clinical practice and education Our findings underscore the challenges for clinicians in the support of adherence behavior of their patients. Despite technological advances and the willingness of patients to incorporate digital health applications into their treatment (42), physiotherapists are still seen as instrumental for the success of treatment by their patients. To effectively use these digital solutions physiotherapists require specific skills, such as technical skills (both for using the technologies, but also to support patients when they experience 8
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