171 General discussion reporting, patient reporting, and observational components, might yield a more accurate reflection of the patient’s adherence behavior (23). To address this gap, we developed the EXAS (chapter 2), which collects information on adherence to frequency, intensity, and quality of performance recommendations. We assessed the construct validity and test-retest reliability of this new instrument (24). However, the EXAS shares some limitations common to other patient-reported measures of adherence, such as the potential for reporting bias (20) and the administrative burden. Although including quality of performance in the assessment of patient adherence is one of the strengths of the EXAS, it is also a limitation. There is currently no consensus on how to incorporate quality of performance in the measurement of adherence, so we had to determine this ourselves based on clinical experience and expert opinion. As a result, it is possible that the EXAS underestimates patient adherence. Another possible limitation could be the way the EXAS attributes therapist-determined factors of the HBE program, such as the number of exercises, recommended sets and repetitions, and exercise type, to the patient when assessing adherence behavior. For example, if a physiotherapist prescribes an impractically large number of exercises, resulting in the patient’s inability to complete the HBE program as recommended, the EXAS may rate the patient’s adherence as low, despite the patient’s best efforts. Nevertheless, the EXAS is currently one of the best instruments available for the measurement of adherence to HBE, which is why we used it in conjunction with the Exercise Adherence Rating Scale (EARS) (25), a 3-month recall measure of adherence, to gain deeper insights into patient adherence during and after treatment (chapter 5). For a more effective measurement of adherence and its impact on the management of patients with LBP, several amendments are advisable for the EXAS. Firstly, to reduce reporting bias, a revision of the EXAS wording is recommended, encouraging patients to report nonadherence rather than adherence. This change is supported by recent findings suggesting that reports of nonadherence tend to be more reliable than those of adherence (17). Secondly, an additional component that enables the collection of data on reasons for nonadherence should be added to each EXAS measurement. This addition would facilitate a better understanding of the factors influencing each patient’s adherence behavior and more effectively explain variations in adherence. It would also allow physiotherapists to determine perceived barriers negatively impacting patient adherence, enabling timely adjustments during treatment. Thirdly, further research is needed to understand the best method for integrating the quality of exercise performance into adherence measurement. This includes evaluating 8
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