26 Chapter 2 instruments focus mainly on adherence to frequency and intensity recommendations of HBE programs (15). However, based on findings in patients with osteoarthritis treated by a physical therapist, quality of performance is an important factor in the treatment effects of HBE programs (16). Patients may perform exercises in the exact frequency and intensity recommended by their physical therapist, but if the quality of performance is lacking, the intended effect of the exercise (e.g. muscle strengthening) is far less likely to be achieved. Poor quality of performance of exercises can be especially problematic when trying to assess the effectiveness of HBE programs for the treatment of patients with LBP in both clinical practice and research environments. Unfortunately, there is currently no instrument that can measure adherence to frequency, intensity, and quality of performance recommendations of HBE programs (9,10,15). Therefore, the aims of the current study are to develop an instrument to measure adherence to frequency, intensity, and quality of performance of HBE programs recommended by a health-care professional and to evaluate its construct validity and reliability. METHODS Development This study was performed in primary care physical therapy practices in the Netherlands. In developing the Exercise Adherence Scale (EXAS), the goal was to create an instrument to be used during face-to-face treatment sessions by a physical therapist or other healthcare professionals to record HBE recommendations and patient-reported adherence to HBE recommendations. Furthermore, an observational component for assessing patients’ quality of performance of HBEs was to be included. The resulting instrument measures patient adherence to HBE recommendations from a physical therapist on intensity, frequency, and quality of performance. The instrument was developed using a three-step process consisting of a literature search to create items, a face and content validity check by an expert panel, and a pilot test involving a small sample of patients. In the first step, the literature was searched for studies reporting on adherence to HBE programs, and the tools used to quantify adherence were extracted where possible. The studies found used primarily patient diaries or short questionnaires aimed at quantifying adherence to intensity and frequency recommendations of HBE programs, such as the Sport Injury Rehabilitation Adherence Scale (17). None of the studies found reported on the quality of performance. Based on these findings, the authors created a first draft of the EXAS with a quality of performance component. In the second step, an expert panel comprising researchers from the fields of health-related measurement instrument creation, LBP, and adherence was created.
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