182 Chapter 9 Low back pain (LBP) is a musculoskeletal condition affecting a significant portion of the adult population globally, leading to substantial disability and economic burden. Clinical guidelines advocate the biopsychosocial model as the basis of LBP management and emphasize patient education, self-management, and interventions centered around physical activity and exercise to promote pain relief and physical well-being. Exercise therapy has been shown to be effective for the management of LBP, but it’s effectiveness varies considerably between patients. Exercise therapy can be delivered face-to-face in clinics, but this is associated with significant costs in time and resources. Therefore, face-to-face physiotherapy is often combined with home-based exercise (HBE) recommendations to increase treatment dosage without increasing treatment costs. However, the effectiveness of these treatments rely on patient adherence, which has shown to be lacking. Despite the recognized importance of adherence to HBE recommendations for positive clinical outcomes, measuring adherence accurately remains challenging, limiting our understanding of its impact on clinical outcomes. The existing literature highlights the potential of digital health technologies, such as smartphone apps, to support adherence to HBE when integrated with existing physiotherapy methods. These blended care treatments aim to enhance engagement, adherence to therapeutic exercises, and overall self-management capabilities of patients. Based on this, we developed the e-Exercise LBP intervention, a novel approach combining an app with traditional face-to-face physiotherapy. The intervention is designed to match the content of the treatment with the patients’ risk for persistent LBP. The app includes self-management themes, a tailored HBE program, and a goal-oriented physical activity module, aiming to support the patient’s activity level and adherence. However, adherence to HBE is complex construct and enhancing our understanding of it could enable clinicians better support their patients, potentially improving treatment outcomes. Therefore, the general aim of this thesis was to develop a new tool to measure adherence to HBE recommendations and use it to investigate adherence and its associations with clinical outcomes and recovery from LBP. Furthermore, we aimed to evaluate the results of the e-Exercise LBP intervention in patients with LBP and investigate patient perspectives regarding the use of a smartphone app as part of treatment. Chapter 2 describes the development, validity testing, and reliability assessment of the Exercise Adherence Scale (EXAS), an instrument designed to measure adherence to HBE for patients with LBP. The EXAS evaluates patient adherence to frequency, intensity, and quality of performance recommendations by physiotherapists. Validity of the EXAS was supported by moderate correlations with lack of time (rho = 0.47) and lack of motivation (rho = 0.48) to exercise, indicating convergent validity, while low correlations with pain (rho = 0.005) and disability (rho = 0.24) confirmed its divergent validity. The instrument
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