71 Effectiveness and cost-effectiveness of e-Exercise low back pain - study protocol Interventions E-exercise LBP A multi-phase development process based on the Center for eHealth Research (CeHRes) Roadmap (37) was used for development of the e-Exercise LBP intervention (33). The e-Exercise LBP intervention integrates eCoaching using a smartphone application within face-to-face physiotherapy. The content is based on recommendations from national and international guidelines (7,8,10), and preferences and needs of patients and physiotherapists (33). The principles of stratified care are used to personalize e-Exercise LBP to individual needs (30,31). Smartphone application The smartphone application consists of three modules (Table 1): (i) An information module containing 12 weekly self-management themes (text and video), including assignments, about the aetiology of LBP, physical activity, patient experiences, pain management, and psychosocial factors related to LBP. (ii) An exercise module including a home-based video-instructed exercise program per prognostic risk profile. The selection, frequency and repetitions can be adjusted by the physiotherapist to address the patient’s specific functional limitations. (iii) A physical activity module containing a goal-oriented training program consisting of three sessions a week, to maintain or improve the level of physical activity for a self-chosen type of activity (e.g., cycling or walking). The training program starts with a 3-day baseline test, and can be optionally supported by graded activity functionality with tailored feedback, which was previously studied in two osteoarthritis studies (35,38). In patients having a “low risk” for developing persistent LBP the smartphone application will offer support for 3 weeks. In “medium” – and “high risk” patients the support will be 12 weeks. Afterwards the content of the smartphone application will remain available for the patients. In “low risk” patients the smartphone application will only contain the information – and exercise modules. In “medium – and high risk” patients the physical activity module will be added. The results of the baseline test of the physical activity module will be used by the physiotherapist and patient to set a goal to reach within 11 weeks. The graded activity functionality can be switched on in “medium risk” patients who avoid physical activity because of LBP. For “high risk” patients the graded activity functionality will always be activated. Print screens of the smartphone application are given in Appendix 1. 4
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