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 through support and 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.