30 Chapter 2 to a physical therapist, between the ages of 20 and 65, and having sufficient command of the Dutch language to read and understand questionnaires and spoken or written instructions. Patients were excluded if they had previously been diagnosed with lumbar radiculopathy, spinal osteoarthritis, or other conditions as the cause of their LBP or if they were unable to perform exercises due to physical or mental issues. Measurements Adherence to HBE. Recommendations were measured with the newly developed EXAS. The EXAS score was calculated using the previously stated assumption of 20% effectiveness for each point on the quality of performance scale. Barriers. The barriers “lack of time to exercise” and “lack of motivation to exercise” were measured using single-item Likert scales based on the barriers subscale used by Sluijs, Kok, and van der Zee (1993) (20). Lack of time to exercise was reported on a 5-point scale ranging from 5 (“always”) to 1 (“never”). Lack of motivation to exercise was measured on a 4-point scale ranging from 1 (“very motivated”) to 4 (“not motivated”). Pain. Pain was measured with the Numeric Rating Scale for pain (NRS Pain) (22–24). Patients were asked to rate the intensity of their current pain on an 11-point numeric scale ranging from 0 (“no pain”) to 10 (“worst pain imaginable”). Disability. Disability was measured with the Dutch language version of the Quebec Back Pain Disability Scale (QBPDS) (25). The QBPDS quantifies disability caused by LBP in daily activities. The questionnaire consists of 20 items, and the total score ranges from 0 (no disability) to 100 (completely restricted). Moderate evidence for positive reliability and validity of the Dutch-language version of the QBPDS has been reported in a review by Speksnijder et al. (2016) (26). Demographics. The following personal and demographic characteristics of the participants were measured: age (in years), gender, height (in centimeters), weight (in kilograms), level of education (i.e. elementary school, high school, vocational school, college, or university), and duration of symptoms (up to 3 months, 3 to 6 months, 6 to 12 months, or more than 12 months). Procedures to test validity All patients with LBP who visited the participating physical therapy practices and agreed to participate were screened for eligibility using the inclusion and exclusion criteria. Written informed consent was obtained from the participants prior to the start of the study. The patients received the usual care, and the physical therapists used the EXAS to record HBE recommendations. Additionally, measurements of pain, disability, barriers, and patient characteristics were completed. One week after the HBE program was recommended to
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