Barriers and facilitators to adherence with home-based exercise in persistent spinal pain - A nested qualitative study

BACKGROUND: Persistent spinal pain is a leading cause of disability worldwide. Home-based exercise is widely recommended as part of a self-management strategy, yet adherence remains sub-optimal. Understanding the barriers and facilitators to engagement is essential for developing effective, patient-centered rehabilitation programs. OBJECTIVES: This study aimed to explore barriers and facilitators to perceived adherence to home-based exercise programs in patients with persistent spinal pain. DESIGN: Qualitative interview study. METHODS: Fourteen individuals with persistent spinal pain were recruited from an ongoing cohort and took part in semi-structured interviews. Data was analyzed using a phenomenological-hermeneutic approach following Braun and Clarke's six-phase process for inductive thematic analysis. RESULTS: Three main themes were identified, reflecting both barriers and facilitators to adherence in home-based exercise programs: 1) 'Engagement throughsupportand accountability', where social contact, group environments, and regular follow-ups were seen as essential for sustaining motivation; 2) 'Pain, expectations, and perseverance', where unrealistic hopes for immediate pain relief and difficulties managing discomfort challenged adherence, while clear communication and normalization of pain fostered persistence; and 3) 'Structure and self-empowering program design', where short, feasible, and co-developed routines promoted ownership, autonomy, and long-term engagement. CONCLUSIONS: Adherence to home-based exercise programs for individuals with persistent spinal pain is influenced by a complex interplay of factors. Incorporating structured support, patient involvement in program design, and realistic pain education may promote sustained engagement and improve the effectiveness of home-based rehabilitation interventions.