27 Development of the Exercise Adherence Scale (EXAS) in patients with low back pain The expert panel provided feedback on the relevance and wording of the EXAS and suggested additions where needed in a two-round iterative process, thereby further refining the instrument. In the last step, five physical therapists pilot-tested the EXAS in patients with LBP to ensure that the questions were comprehensible and unambiguous. Based on feedback from the physical therapists and their patients, the final version of the EXAS was produced. The final version of the EXAS is an interview-based instrument with an observational component, completed by the physical therapist together with the patient during each of the patient’s visits (Supplemental File). During the patient’s first treatment session, the physical therapist records the recommendations for the HBE program (i.e. type of exercises, frequency, and intensity) and shares them with the patient. During the patient’s follow-up visits, the physical therapist uses the EXAS to record the frequency and intensity of HBE performance as reported by the patient in a standardized format. Additionally, the physical therapist asks the patient to perform the exercises and rates the quality of performance on a 5-point scale (i.e. poor, moderate, reasonable, good, and excellent). The EXAS contains a qualitative description for the “poor,” “reasonable,” and “excellent” categories to facilitate the rating process (Table 1). Based on the experiences of the physical therapists in the pilot test, completing the EXAS requires approximately five minutes. The EXAS score for the HBE program is calculated in three steps. In step one, the ratio between the frequency and intensity of HBE performance reported by the patient and the corresponding recommendations from the physical therapist is calculated for each exercise and multiplied by 100 to determine the adherence rate [1]. If the patientreported performance of frequency and intensity exceeds therapist recommendations, an adherence rate of 100% is scored instead. Adherence rate = Number of days * number of times per day * sets * repetitions reported by the patient Number of days * number of times per day * sets * repetitions recommended by the therapist) * 100 [1] In step two, the quality of performance score is used to calculate the adherence score for the individual exercise. To obtain the adherence score, the adherence rate for the individual exercise is multiplied by the quality of performance score for the individual exercise [2]. Adherence score=Adherence rate*quality of performance score [2] 2
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