67 Effectiveness and cost-effectiveness of e-Exercise low back pain - study protocol BACKGROUND Low back pain (LBP) is the most common cause of disability in western society (1). LBP causes a significant economic burden and is responsible for high direct healthcare costs as well as high indirect costs due to time lost from work (2). LBP can be caused by a specific pathology or trauma; however, in more than 90% of cases an underlying disease is absent (3,4). The clinical course of this so-called ‘non-specific LBP’ varies; some people recover within a couple of days or weeks, and other people experience persistent disabling symptoms leading to chronic LBP (2,5,6). Both national and international clinical LBP guidelines endorse patient education, advice on returning to normal activities and the prescription of home-exercises and/or supervised exercise therapy (7–10). However, the effectiveness of physiotherapy in patients with LBP does not solely depend on providing the most adequate physiotherapy interventions. It also highly depends on patients’ adherence to prescribed (home) exercises and recommended physical activity behaviour (11,12). Earlier research showed that 45–70% of patients do not adhere to prescribed exercises and physical activity recommendations (13–15), whereas adherent patients with LBP who continue a physically active lifestyle have a reduced risk of recurrent LBP (16). Therefore, supporting self- management and adherence in patients with LBP is expected to be essential for the effectiveness of physiotherapy interventions on patients’ physical functioning and prevention of recurrent events. Online applications, such as websites and apps, provide new solutions to support patients’ ability to manage their physical functioning in their home environment, and are promising to support self-management and adherence to prescribed (home) exercises between face-to- face sessions (17–20). Consequently, the integration of online applications into healthcare, so- called blended care (21), is expected to have several advantages for patients with LBP. Firstly, a blended intervention can stimulate self-management and exercise adherence to prescribed (home) exercises and recommended physical activity behaviour in patients with LBP by its 24/7 online support and persuasive design (20,22– 24). Secondly, the use of online applications enables monitoring and coaching of the patients’ individual health behaviour and provides the physiotherapist with information to optimize and tailor face-to-face care to the patients’ individual needs (22,23,25–27). Despite all these benefits, matching the appropriate blended treatment for the individual patient is reported as a challenge (28). To resolve this challenge within traditional face-toface guidance, stratification tools have gained more attention in the last decade. Within a stratified-care approach, the treatment is matched upon the patients’ risk of developing persistent LBP, for example determined with the Keele STarT Back Screening Tool (29). Research showed that such an approach results in improved physical functioning and satisfaction with care among patients with LBP while reducing costs of healthcare in both 4
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