Technology Supported High Intensity Training in Chronic Low Back Pain: the Techno-HIT Trial
NCT Number: NCT06491121
Acronym: TECHNO-HIT
Status: RECRUITING
Study Type: INTERVENTIONAL
Phases: NA
Conditions: Chronic Low-back Pain|Exercise Therapy|Telerehabilitation
Interventions: OTHER: Technology supported High Intensity Training|OTHER: Moderate Intensity Training|OTHER: High Intensity Training
Sponsor: Hasselt University
Sex: ALL
Age: ADULT, OLDER_ADULT
Enrollment: 168
Study Design: Allocation: RANDOMIZED|Intervention Model: PARALLEL|Masking: DOUBLE (INVESTIGATOR, OUTCOMES_ASSESSOR)|Primary Purpose: OTHER
Start Date: 2024-05-27
Completion Date: 2029-03
Locations: Universitair Ziekenhuis Antwerpen (UZA), Wilrijk, Antwerpen, 2610, Belgium|University of Antwerp, Wilrijk, Antwerpen, 2610, Belgium|Hasselt University, Diepenbeek, Limburg, 3590, Belgium|Jessa Ziekenhuis, Hasselt, 3500, Belgium

Summary:
Chronic low back pain (CLBP) is one of the most common chronic musculoskeletal disorder worldwide and is responsible for the highest levels of disability of all diseases. All state-of-the-art guidelines recommend implementing exercise therapy (ET) in CLBP management. Researchers have shown that a novel ET modality, namely high intensity training (HIT), can be valuable. A clinical evaluation study in a larger spectrum of persons with CLBP in a rehabilitation centre setting is essential. Thereby, technology might support HIT.

The primary goal of this clinical trial is to evaluate the short- and long-term effectiveness of a time contingent individualized High intensity training (HIT) protocol on disability compared to moderate intensity training (MIT) in persons with severely disabling chronic low back pain (CLBP). Secondary goals entail 1) evaluating short- and long-term effectiveness of HIT on psychosocial correlates, central pain processing, and broad physical fitness, 2) investigating additional effects of (prolonged) HIT at home, 3) investigating added value of technology through a mobile (smartphone) and dashboard (computer) application that offers support during home training, 4) evaluating cost-effectiveness of (technology supported) HIT compared to MIT. The main research question\[s\] (RQ) it aims to answer are:

* RQ1: To what extent is HIT effective on the short- and long term to improve disability in persons with severely disabling CLBP compared to MIT as used in usual care?
* RQ2a: To what extent does HIT have a short- and/or long-term effect on central pain processing and psychosocial correlates in persons with severely disabling CLBP?
* RQ2b:To what extent does HIT have a short- and/or long-term effect on outcomes related to broad physical fitness in persons with severely disabling CLBP?
* RQ3a: To what extent does prolonged (technology-supported) HIT at home provide additional training effects in persons with severely disabling CLBP?
* RQ3b:To what extent does a mobile application that offers support for HIT at home provide added value for treatment outcomes of persons with severely disabling CLBP?
* RQ3c:To what extent is the techno-HIT application usable and qualitative (assessed by SUS and uMARS) as a therapeutic support mechanism, as evaluated by persons with severely disabling CLBP?
* RQ4: To what extent is HIT or HIT supported by a mobile application cost effective compared to MIT for patients with severely disabling CLBP?

Primary Outcome Measures: Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T0: PRE (post biopsychosocial education program, at the start of intervention)|Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T1: MID (After completing the 12-week protocol in hospital)|Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T2: POST (After completing the 12-week protocol at home)|Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T3: POST (6 months follow-up)|Modified Oswestry Disability Index (MODI) questionnaire - Time necessary for completion: 5 min, This questionnaire is used to evaluate disability and consists of ten items scored on a five-point scale (0-5) whereby zero means minimal disability and five means very severe disability. A percentage of restriction for the patient can be indicated on the basis of the total score. This questionnaire is reliable and valid for use in persons with chronic low back pain., T4: POST (18 months follow-up)
Secondary Outcome Measures: Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T0: PRE (post biopsychosocial education program, at the start of intervention)|Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T1: MID (After completing the 12-week protocol in hospital)|Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T2: POST (After completing the 12-week protocol at home)|Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T3: POST (6 months follow-up)|Brief Pain Inventory (BPI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate (widespread) pain and consists of 9-items including a body chart to draw the pain region. A high score corresponds to more pain., T4: POST (18 months follow-up)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T0: PRE (post biopsychosocial education program, at the start of intervention)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T1: MID (After completing the 12-week protocol in hospital)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T2: POST (After completing the 12-week protocol at home)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T3: POST (6 months follow-up)|Quantitative sensory testing (QST) thermal stimuli - Time necessary for completion: 30 min, QST will be used to examine nociceptive processing of pain by applying various thermal stimuli at affected and remote sites. Advanced thermal stimulation will be assessed with the TSA II (Medoc), including thermal pain thresholds, temporal summation, and conditioned pain modulation (CPM). CPM will be examined to evaluate the endogenous analgesic system, by examining the change in pain perceived in one body region (test stimulation) as a result of pain induced in another body region (conditioned stimulation)., T4: POST (18 months follow-up)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T0: PRE (post biopsychosocial education program, at the start of intervention)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T1: MID (After completing the 12-week protocol in hospital)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T2: POST (After completing the 12-week protocol at home)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T3: POST (6 months follow-up)|Quantitative sensory testing (QST) Pinprick stimulator - Time necessary for completion: 5 min, Temporal summation will additionally be measured with the PinPrick-stimulator (MRC systems, 256mN) that will be repeatedly applied on the skin on the non-dominant forearm and the lower back, following a predefined standardized protocol. Wind-up ratio (WUR) is calculated comparing a single pinprick stimulus to trains of 10 pinprick stimuli. Stimuli are applied at a 1/s rate over a small area (1cm2) and the participant is asked to rate the pain on a scale of 0-100., T4: POST (18 months follow-up)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T0: PRE (post biopsychosocial education program, at the start of intervention)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T1: MID (After completing the 12-week protocol in hospital)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T2: POST (After completing the 12-week protocol at home)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T3: POST (6 months follow-up)|Work Ability Index (WAI) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-perceived work ability in seven categories. The total score can range from 7 to 49 points with higher scores indicating better work ability, T4: POST (18 months follow-up)|Brief Resilience Scale (BRS-NL)- Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Brief Resilience Scale (BRS-NL)- Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T0: PRE (post biopsychosocial education program, at the start of intervention)|Brief Resilience Scale (BRS-NL)- Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T1: MID (After completing the 12-week protocol in hospital)|Brief Resilience Scale (BRS-NL)- Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T2: POST (After completing the 12-week protocol at home)|Brief Resilience Scale (BRS-NL)- Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T3: POST (6 months follow-up)|Brief Resilience Scale (BRS-NL) - Time necessary for completion: 2 min, This questionnaire is used to evaluate the degree of individual resilience. The items of this self-report questionnaire are scored on a 5-point Likert scale. Possible scores are ranging from 1 to 5. A higher score corresponds to being more resilient than a lower score., T4: POST (18 months follow-up)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T0: PRE (post biopsychosocial education program, at the start of intervention)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T1: MID (After completing the 12-week protocol in hospital)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T2: POST (After completing the 12-week protocol at home)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T3: POST (6 months follow-up)|Tampa Scale for Kinesiophobia (TSK) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear of movement and fear of (re)injury on a 4-point Likert scale ranging from "strongly disagree" to "strongly agree". Items 4, 8, 12 and 16 are inversely phrased. A higher score indicates higher levels of kinesiophobia., T4: POST (18 months follow-up)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T0: PRE (post biopsychosocial education program, at the start of intervention)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T1: MID (After completing the 12-week protocol in hospital)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T2: POST (After completing the 12-week protocol at home)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T3: POST (6 months follow-up)|Fear-Avoidance Components Scale (FACS) - Time necessary for completion: 10 min, This questionnaire is used to evaluate fear avoidance in patients with painful medical conditions. Each item is scored on a 6-point Likert scale, resulting in scores ranging from zero ("completely disagree") to five ("completely agree"). There is a maximum total score of 100, with higher scores indicating more fear-avoidance. Five severity levels have been proposed: subclinical (0-20), mild (21-40), moderate (41- 60), severe (61-80), and extreme (81-100). The FACS-D has good reliability and validity in persons with chronic musculoskeletal pain, T4: POST (18 months follow-up)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T0: PRE (post biopsychosocial education program, at the start of intervention)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T1: MID (After completing the 12-week protocol in hospital)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T2: POST (After completing the 12-week protocol at home)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T3: POST (6 months follow-up)|Self-Efficacy for Exercise (SEE) - Time necessary for completion: 5 min, This questionnaire is used to evaluate self-efficacy expectations related to the ability to continue exercising in the face of barriers to exercise. A higher score indicates higher self-efficacy for exercise., T4: POST (18 months follow-up)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T0: PRE (post biopsychosocial education program, at the start of intervention)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T1: MID (After completing the 12-week protocol in hospital)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T2: POST (After completing the 12-week protocol at home)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T3: POST (6 months follow-up)|Expectation to recover (ETR) - Time necessary for completion: 1 min, This nominal scales is used to evaluate treatment expectation and consist of a line indicating eleven successive scores (0-10), whereby zero means 'no succes' and ten means 'very good recovery'., T4: POST (18 months follow-up)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T0: PRE (post biopsychosocial education program, at the start of intervention)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T1: MID (After completing the 12-week protocol in hospital)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T2: POST (After completing the 12-week protocol at home)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T3: POST (6 months follow-up)|Brief Illness Perception Questionnaire (b-IPQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate cognitive and emotional representations of illness. The Brief IPQ uses a single-item scale approach to assess perception on a 0-10 response scale. . A higher score indicates more negative perceptions., T4: POST (18 months follow-up)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T0: PRE (post biopsychosocial education program, at the start of intervention)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T1: MID (After completing the 12-week protocol in hospital)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T2: POST (After completing the 12-week protocol at home)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T3: POST (6 months follow-up)|Injustice Experience Questionnaire (IEQ) - Time necessary for completion: 5 min, This questionnaire is used to evaluate perceived injustice and consists of of 12 items, scored on a range from zero "not at all" to four "all the time". Higher total scores reflect higher levels of perceived injustice. Cut-off scores of 19 and 30 are reported for medium and high levels of perceived injustice, respectively., T4: POST (18 months follow-up)|A maximal cardiopulmonary exercise test - Time necessary for completion: 30 min, A bicycle ergometer (eBike Basic, General Electric GmbH, Bitz, Germany) with pulmonary gas exchange analysis (MetaMax 3B, Cortex Biophysik GmbH, Leipzig, Germany) will be used. Herein, a low workload gradually increases each minute (30W+15W/min). Maximal oxygen uptake (VO2max) and maximal workload through cycling time (min.) are evaluated through breath-by-breath gas exchange analysis and heartrate monitoring (H10, Polar Electro). A minimum respiratory exchange ratio (RER) threshold of 1.10 is used to evaluate proper validity of the maximum effort., T0: PRE (post biopsychosocial education program, at the start of intervention)|A maximal cardiopulmonary exercise test - Time necessary for completion: 30 min, A bicycle ergometer (eBike Basic, General Electric GmbH, Bitz, Germany) with pulmonary gas exchange analysis (MetaMax 3B, Cortex Biophysik GmbH, Leipzig, Germany) will be used. Herein, a low workload gradually increases each minute (30W+15W/min). Maximal oxygen uptake (VO2max) and maximal workload through cycling time (min.) are evaluated through breath-by-breath gas exchange analysis and heartrate monitoring (H10, Polar Electro). A minimum respiratory exchange ratio (RER) threshold of 1.10 is used to evaluate proper validity of the maximum effort., T1: MID (After completing the 12-week protocol in hospital)|A maximal cardiopulmonary exercise test - Time necessary for completion: 30 min, A bicycle ergometer (eBike Basic, General Electric GmbH, Bitz, Germany) with pulmonary gas exchange analysis (MetaMax 3B, Cortex Biophysik GmbH, Leipzig, Germany) will be used. Herein, a low workload gradually increases each minute (30W+15W/min). Maximal oxygen uptake (VO2max) and maximal workload through cycling time (min.) are evaluated through breath-by-breath gas exchange analysis and heartrate monitoring (H10, Polar Electro). A minimum respiratory exchange ratio (RER) threshold of 1.10 is used to evaluate proper validity of the maximum effort., T2: POST (After completing the 12-week protocol at home)|A maximal cardiopulmonary exercise test - Time necessary for completion: 30 min, A bicycle ergometer (eBike Basic, General Electric GmbH, Bitz, Germany) with pulmonary gas exchange analysis (MetaMax 3B, Cortex Biophysik GmbH, Leipzig, Germany) will be used. Herein, a low workload gradually increases each minute (30W+15W/min). Maximal oxygen uptake (VO2max) and maximal workload through cycling time (min.) are evaluated through breath-by-breath gas exchange analysis and heartrate monitoring (H10, Polar Electro). A minimum respiratory exchange ratio (RER) threshold of 1.10 is used to evaluate proper validity of the maximum effort., T3: POST (6 months follow-up)|A maximal cardiopulmonary exercise test - Time necessary for completion: 30 min, A bicycle ergometer (eBike Basic, General Electric GmbH, Bitz, Germany) with pulmonary gas exchange analysis (MetaMax 3B, Cortex Biophysik GmbH, Leipzig, Germany) will be used. Herein, a low workload gradually increases each minute (30W+15W/min). Maximal oxygen uptake (VO2max) and maximal workload through cycling time (min.) are evaluated through breath-by-breath gas exchange analysis and heartrate monitoring (H10, Polar Electro). A minimum respiratory exchange ratio (RER) threshold of 1.10 is used to evaluate proper validity of the maximum effort., T4: POST (18 months follow-up)|International Physical Activity Questionnaire short form (IPAQ-sf) - Time necessary for completion: 5 min, This questionnaire is used to estimate physical activity level. The questionnaire consists of 7 questions. A higher score corresponds to a more physically demanding activity level. This questionnaire is reliable and valid for use in persons with chronic low back pain., T0: PRE (post biopsychosocial education program, at the start of intervention)|International Physical Activity Questionnaire short form (IPAQ-sf) - Time necessary for completion: 5 min, This questionnaire is used to estimate physical activity level. The questionnaire consists of 7 questions. A higher score corresponds to a more physically demanding activity level. This questionnaire is reliable and valid for use in persons with chronic low back pain., T1: MID (After completing the 12-week protocol in hospital)|International Physical Activity Questionnaire short form (IPAQ-sf) - Time necessary for completion: 5 min, This questionnaire is used to estimate physical activity level. The questionnaire consists of 7 questions. A higher score corresponds to a more physically demanding activity level. This questionnaire is reliable and valid for use in persons with chronic low back pain., T2: POST (6 months follow-up)|International Physical Activity Questionnaire short form (IPAQ-sf) - Time necessary for completion: 5 min, This questionnaire is used to estimate physical activity level. The questionnaire consists of 7 questions. A higher score corresponds to a more physically demanding activity level. This questionnaire is reliable and valid for use in persons with chronic low back pain., T3: POST (18 months follow-up)|Pittsburg Sleep Quality Index (PSQI) - Time necessary for completion: 10 min, This questionnaire (19 items, three-point scale) evaluates last month's sleep quality in seven domains: sleep latency time, sleep duration, sleep medication, daytime functioning, sleep-related problems, T0: PRE (post biopsychosocial education program, at the start of intervention)|Pittsburg Sleep Quality Index (PSQI) - Time necessary for completion: 10 min, This questionnaire (19 items, three-point scale) evaluates last month's sleep quality in seven domains: sleep latency time, sleep duration, sleep medication, daytime functioning, sleep-related problems, T1: MID (After completing the 12-week protocol in hospital)|Pittsburg Sleep Quality Index (PSQI) - Time necessary for completion: 10 min, This questionnaire (19 items, three-point scale) evaluates last month's sleep quality in seven domains: sleep latency time, sleep duration, sleep medication, daytime functioning, sleep-related problems, T2: POST (After completing the 12-week protocol at home)|Pittsburg Sleep Quality Index (PSQI) - Time necessary for completion: 10 min, This questionnaire (19 items, three-point scale) evaluates last month's sleep quality in seven domains: sleep latency time, sleep duration, sleep medication, daytime functioning, sleep-related problems, T3: POST (6 months follow-up)|Pittsburg Sleep Quality Index (PSQI) - Time necessary for completion: 10 min, This questionnaire (19 items, three-point scale) evaluates last month's sleep quality in seven domains: sleep latency time, sleep duration, sleep medication, daytime functioning, sleep-related problems, T4: POST (18 months follow-up)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T0: PRE (post biopsychosocial education program, at the start of intervention)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T1: MID (After completing the 12-week protocol in hospital)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T2: POST (After completing the 12-week protocol at home)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T3: POST (6 months follow-up)|Heart rate variability (HRV) - Time necessary for completion: 20 min, To evaluate cardiac autonomic function, HRV will be measured. Patients are guided to a quiet low stimulus room and instructed to remain in a supine position for 7 min before beat-to-beat intervals (R-R) are registered using a validated heart rate band (H10, Polar Electro) synchronized with a heart rate monitor (Ignite, Polar Electro). RR data will be extracted using Polar Flow software. The first two minutes are not included to guarantee a steady heart rate. Artefact correction is set at very low. Raw RR data will be analysed with HRV software (Kubios HRV, Kubios Oy) and includes time domain analysis, frequency domain analysis, nonlinear analysis, and time- frequency analysis., T4: POST (18 months follow-up)|The EuroQoL EQ-5D - Time necessary for completion: 10 min, This questionnaire is used to evaluate to collect health-related Quality of Life (QoL). This validated Dutch questionnaire measures QoL using five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A high score corresponds to a better QOL., T0: PRE (post biopsychosocial education program, at the start of intervention)|The EuroQoL EQ-5D - Time necessary for completion: 10 min, This questionnaire is used to evaluate to collect health-related Quality of Life (QoL). This validated Dutch questionnaire measures QoL using five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A high score corresponds to a better QOL., T1: MID (After completing the 12-week protocol in hospital)|The EuroQoL EQ-5D - Time necessary for completion: 10 min, This questionnaire is used to evaluate to collect health-related Quality of Life (QoL). This validated Dutch questionnaire measures QoL using five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A high score corresponds to a better QOL., T2: POST (After completing the 12-week protocol at home)|The EuroQoL EQ-5D - Time necessary for completion: 10 min, This questionnaire is used to evaluate to collect health-related Quality of Life (QoL). This validated Dutch questionnaire measures QoL using five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A high score corresponds to a better QOL., T3: POST (6 months follow-up)|The EuroQoL EQ-5D - Time necessary for completion: 10 min, This questionnaire is used to evaluate to collect health-related Quality of Life (QoL). This validated Dutch questionnaire measures QoL using five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. A high score corresponds to a better QOL., T4: POST (18 months follow-up)|The number of completed therapy sessions - Time necessary for completion: 1 min, The number of completed therapy sessions within the protocol will be registered during the execution of the intervention (at the hospital and at home). Reasons for non-adherence will be inventoried., T1: MID (After completing the 12-week protocol in hospital)|The number of completed therapy sessions - Time necessary for completion: 1 min, The number of completed therapy sessions within the protocol will be registered during the execution of the intervention (at the hospital and at home). Reasons for non-adherence will be inventoried., T2: POST (After completing the 12-week protocol at home)|The number of completed therapy sessions - Time necessary for completion: 1 min, The number of completed therapy sessions within the protocol will be registered during the execution of the intervention (at the hospital and at home). Reasons for non-adherence will be inventoried., T3: POST (6 months follow-up)|The number of completed therapy sessions - Time necessary for completion: 1 min, The number of completed therapy sessions within the protocol will be registered during the execution of the intervention (at the hospital and at home). Reasons for non-adherence will be inventoried., T4: POST (18 months follow-up)|Exercise adherence rating Scale (EARS) - Time necessary for completion: 10 min, The adherence to prescribed home exercises will be assessed using EARS, a 16-item questionnaire. A higher score indicates higher adherence., T1: MID (After completing the 12-week protocol in hospital)|Exercise adherence rating Scale (EARS) - Time necessary for completion: 10 min, The adherence to prescribed home exercises will be assessed using EARS, a 16-item questionnaire. A higher score indicates higher adherence., T2: POST (After completing the 12-week protocol at home)|Exercise adherence rating Scale (EARS) - Time necessary for completion: 10 min, The adherence to prescribed home exercises will be assessed using EARS, a 16-item questionnaire. A higher score indicates higher adherence., T3: POST (6 months follow-up)|Exercise adherence rating Scale (EARS) - Time necessary for completion: 10 min, The adherence to prescribed home exercises will be assessed using EARS, a 16-item questionnaire. A higher score indicates higher adherence., T4: POST (18 months follow-up)|System Usability Scale (SUS) - Time necessary for completion: 5 min, Participants will complete this questionnaire to assess perceived usability of the smartphone application. SUS is a standard 10-item questionnaire in which responses are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Questions 1, 3, 5, 7, and 9 are positive and questions 2, 4, 6, 8, and 10 are negative. A total SUS score is derived by summing the individual scores and multiplying by 2.5, which yields a score ranging between 0 (worst) and 100 (absolute best). A score \>68 is considered above average usability and \>80 considered high usability and a level at which participants are likely to recommend the product to peers., T2: POST (After completing the 12-week protocol at home)|System Usability Scale (SUS) - Time necessary for completion: 5 min, Participants will complete this questionnaire to assess perceived usability of the smartphone application. SUS is a standard 10-item questionnaire in which responses are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Questions 1, 3, 5, 7, and 9 are positive and questions 2, 4, 6, 8, and 10 are negative. A total SUS score is derived by summing the individual scores and multiplying by 2.5, which yields a score ranging between 0 (worst) and 100 (absolute best). A score \>68 is considered above average usability and \>80 considered high usability and a level at which participants are likely to recommend the product to peers., T3: POST (6 months follow-up)|System Usability Scale (SUS) - Time necessary for completion: 5 min, Participants will complete this questionnaire to assess perceived usability of the smartphone application. SUS is a standard 10-item questionnaire in which responses are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Questions 1, 3, 5, 7, and 9 are positive and questions 2, 4, 6, 8, and 10 are negative. A total SUS score is derived by summing the individual scores and multiplying by 2.5, which yields a score ranging between 0 (worst) and 100 (absolute best). A score \>68 is considered above average usability and \>80 considered high usability and a level at which participants are likely to recommend the product to peers., T4: POST (18 months follow-up)|User Version of the Mobile Application Rating Scale (uMARS)- Time necessary for completion: 5 min, The uMARS is a a 20-item questionnaire that includes 4 objective quality subscales: engagement, functionality, aesthetics, and information quality, and 1 subjective quality subscale. Each item is scored on a 5-point Likert scale. Both individual items aswell as a mean overall score can be used for evaluation., T2: POST (After completing the 12-week protocol at home)|User Version of the Mobile Application Rating Scale (uMARS)- Time necessary for completion: 5 min, The uMARS is a a 20-item questionnaire that includes 4 objective quality subscales: engagement, functionality, aesthetics, and information quality, and 1 subjective quality subscale. Each item is scored on a 5-point Likert scale. Both individual items aswell as a mean overall score can be used for evaluation., T3: POST (6 months follow-up)|User Version of the Mobile Application Rating Scale (uMARS)- Time necessary for completion: 5 min, The uMARS is a a 20-item questionnaire that includes 4 objective quality subscales: engagement, functionality, aesthetics, and information quality, and 1 subjective quality subscale. Each item is scored on a 5-point Likert scale. Both individual items aswell as a mean overall score can be used for evaluation., T4: POST (18 months follow-up)|Intrinsic Motivation Inventory (IMI) - Time necessary for completion: 10 min, This is a nominal 35 item questionnaire that assesses the multidimensional subjective experience while performing a certain activity yielding six subscales (interest/enjoyment, perceived competence, effort, value/usefulness, felt pressure and tension, and perceived choice), with the possibility of independent scoring for each scale and a general scoring. A higher score correlates to higher intrinsic motivation (total range 35-245)., T2: POST (After completing the 12-week protocol at home)|Intrinsic Motivation Inventory (IMI) - Time necessary for completion: 10 min, This is a nominal 35 item questionnaire that assesses the multidimensional subjective experience while performing a certain activity yielding six subscales (interest/enjoyment, perceived competence, effort, value/usefulness, felt pressure and tension, and perceived choice), with the possibility of independent scoring for each scale and a general scoring. A higher score correlates to higher intrinsic motivation (total range 35-245)., T3: POST (6 months follow-up)|Intrinsic Motivation Inventory (IMI) - Time necessary for completion: 10 min, This is a nominal 35 item questionnaire that assesses the multidimensional subjective experience while performing a certain activity yielding six subscales (interest/enjoyment, perceived competence, effort, value/usefulness, felt pressure and tension, and perceived choice), with the possibility of independent scoring for each scale and a general scoring. A higher score correlates to higher intrinsic motivation (total range 35-245)., T4: POST (18 months follow-up)|iMTA Productivity Cost Questionnaire (iPCQ) - Time necessary for completion: 15 min, absenteeism at work/loss of productivity will be evaluated using the IPCQ. iPCQ includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presentism, and 3) productivity losses due to unpaid work. iPCQ delivers necessary input to calculate costs associated to productivity loss using the Human Capital Approach for short-term absence and Friction Cost Method for long-term absence. The HCA values the time during the whole period of work inability due to sick leave by multiplying total number of days of work absenteeism by national average labor costs per day. FCM calculates the value of productivity loss by multiplying national labor costs per day by the friction period (i.e. time span to restore initial production level after an employee becomes absent from work). In accordance with KCE guidelines, informal home care (i.e. care by relatives and family) and unpaid work will be measured, but not valued., T1: MID (After completing the 12-week protocol in hospital)|iMTA Productivity Cost Questionnaire (iPCQ) - Time necessary for completion: 15 min, absenteeism at work/loss of productivity will be evaluated using the IPCQ. iPCQ includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presentism, and 3) productivity losses due to unpaid work. iPCQ delivers necessary input to calculate costs associated to productivity loss using the Human Capital Approach for short-term absence and Friction Cost Method for long-term absence. The HCA values the time during the whole period of work inability due to sick leave by multiplying total number of days of work absenteeism by national average labor costs per day. FCM calculates the value of productivity loss by multiplying national labor costs per day by the friction period (i.e. time span to restore initial production level after an employee becomes absent from work). In accordance with KCE guidelines, informal home care (i.e. care by relatives and family) and unpaid work will be measured, but not valued., T2: POST (After completing the 12-week protocol at home)|iMTA Productivity Cost Questionnaire (iPCQ) - Time necessary for completion: 15 min, absenteeism at work/loss of productivity will be evaluated using the IPCQ. iPCQ includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presentism, and 3) productivity losses due to unpaid work. iPCQ delivers necessary input to calculate costs associated to productivity loss using the Human Capital Approach for short-term absence and Friction Cost Method for long-term absence. The HCA values the time during the whole period of work inability due to sick leave by multiplying total number of days of work absenteeism by national average labor costs per day. FCM calculates the value of productivity loss by multiplying national labor costs per day by the friction period (i.e. time span to restore initial production level after an employee becomes absent from work). In accordance with KCE guidelines, informal home care (i.e. care by relatives and family) and unpaid work will be measured, but not valued., T3: POST (6 months follow-up)|iMTA Productivity Cost Questionnaire (iPCQ) - Time necessary for completion: 15 min, absenteeism at work/loss of productivity will be evaluated using the IPCQ. iPCQ includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presentism, and 3) productivity losses due to unpaid work. iPCQ delivers necessary input to calculate costs associated to productivity loss using the Human Capital Approach for short-term absence and Friction Cost Method for long-term absence. The HCA values the time during the whole period of work inability due to sick leave by multiplying total number of days of work absenteeism by national average labor costs per day. FCM calculates the value of productivity loss by multiplying national labor costs per day by the friction period (i.e. time span to restore initial production level after an employee becomes absent from work). In accordance with KCE guidelines, informal home care (i.e. care by relatives and family) and unpaid work will be measured, but not valued., T4: POST (18 months follow-up)|In-hospital costs - Time necessary for completion: 5 min, The in-hospital costs of participants will be calculated using accounting records of the participating hospitals, which are highly comparable since both use a standardized program in each of the three groups. Most important in-hospital cost categories are: rehabilitation, medication and devices, consultation fees, staff fees, surgeries. This list is however not exhaustive. The hospitals' accounting information will give more insight in the interventions and medication given to participants., T1: MID (After completing the 12-week protocol in hospital)|In-hospital costs - Time necessary for completion: 5 min, The in-hospital costs of participants will be calculated using accounting records of the participating hospitals, which are highly comparable since both use a standardized program in each of the three groups. Most important in-hospital cost categories are: rehabilitation, medication and devices, consultation fees, staff fees, surgeries. This list is however not exhaustive. The hospitals' accounting information will give more insight in the interventions and medication given to participants., T2: POST (After completing the 12-week protocol at home)|In-hospital costs - Time necessary for completion: 5 min, The in-hospital costs of participants will be calculated using accounting records of the participating hospitals, which are highly comparable since both use a standardized program in each of the three groups. Most important in-hospital cost categories are: rehabilitation, medication and devices, consultation fees, staff fees, surgeries. This list is however not exhaustive. The hospitals' accounting information will give more insight in the interventions and medication given to participants., T3: POST (6 months follow-up)|In-hospital costs - Time necessary for completion: 5 min, The in-hospital costs of participants will be calculated using accounting records of the participating hospitals, which are highly comparable since both use a standardized program in each of the three groups. Most important in-hospital cost categories are: rehabilitation, medication and devices, consultation fees, staff fees, surgeries. This list is however not exhaustive. The hospitals' accounting information will give more insight in the interventions and medication given to participants., T4: POST (18 months follow-up)|Healthcare utilization costs - Time necessary for completion: 5 min, a self-reported healthcare utilization questionnaire will be used by PEC-UH to measure the out-of-hospital healthcare utilization and costs (additional, extramural medical interventions and medication related to CLBP)., T3: POST (6 months follow-up)|Healthcare utilization costs - Time necessary for completion: 5 min, a self-reported healthcare utilization questionnaire will be used by PEC-UH to measure the out-of-hospital healthcare utilization and costs (additional, extramural medical interventions and medication related to CLBP)., T4: POST (18 months follow-up)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T0: PRE (post biopsychosocial education program, at the start of intervention)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T1: MID (After completing the 12-week protocol in hospital)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T2: POST (After completing the 12-week protocol at home)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T3: POST (6 months follow-up)|C-reactive protein (CRP) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify CRP levels using the QuickRead Go by Aidian, Finland., T4: POST (18 months follow-up)|Hemoglobin A1c (HbA1c) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify glucose concentration in the bloodstream using the QuickRead Go by Aidian, Finland., T0: PRE (post biopsychosocial education program, at the start of intervention)|Hemoglobin A1c (HbA1c) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify glucose concentration in the bloodstream using the QuickRead Go by Aidian, Finland., T1: MID (After completing the 12-week protocol in hospital)|Hemoglobin A1c (HbA1c) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify glucose concentration in the bloodstream using the QuickRead Go by Aidian, Finland., T2: POST (After completing the 12-week protocol at home)|Hemoglobin A1c (HbA1c) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify glucose concentration in the bloodstream using the QuickRead Go by Aidian, Finland., T3: POST (6 months follow-up)|Hemoglobin A1c (HbA1c) testing - Time necessary for completion: 2 min, A non-invasive finger-prick blood sampling technique will quantify glucose concentration in the bloodstream using the QuickRead Go by Aidian, Finland., T4: POST (18 months follow-up)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T-1: PRE (pre biopsychosocial education program, 2 weeks before the start of intervention)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T0: PRE (post biopsychosocial education program, at the start of intervention)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T1: MID (After completing the 12-week protocol in hospital)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T2: POST (After completing the 12-week protocol at home)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T3: POST (6 months follow-up)|Positive and Negative Affect Schedule (PANAS) - Time necessary for completion: 5 min, This questionnaire is used to evaluate participants' emotional states and fluctuations on a 5-point Likert scale and consists of 10 items representing positive affect dimensions and 10 items representing negative affect dimensions., T4: POST (18 months follow-up)