36 Chapter 2 is the scale on which quality of the performance was rated. In the study by Hermet et al. (2018), a 10-point rating scale was used (32), whereas, in the current study, a 5-point ordinal scale with additional explanation was used to provide a more standardized means of interpreting the different ratings. The results for interrater reliability of the EXAS quality of performance are poor. This finding is almost identical to the results of Hermet et al. (2018) (32), who found an interrater reliability of 0.34 (95%-CI 0.07–0.48) for primary care physical therapists rating strength exercises. They proposed that different backgrounds and expectations between physical therapists might be the cause of low interrater reliability, as higher reliability scores were found in trained physical therapists. The large number of disagreements between ratings by untrained therapists in the current study appears to support this hypothesis when compared with the much lower number of disagreements between repeated ratings by the same therapist. As a result, clinicians and researchers using the EXAS to assess adherence to HBE programs should consider training or instructing healthcare professionals in the scoring of quality of performance to increase interrater reliability. During the data collection phase of the current study, a new measure of adherence was published (33). The Exercise Adherence Rating Scale (EARS) is a 6-item questionnaire aimed at measuring adherence behavior and exploring reasons for nonadherence. The full instrument consists of three sections: Prescribed Exercise Questionnaire (Section A), Exercise Adherence Rating Scale (EARS) (Section B), and What helps or hinders doing your exercises? (Section C) (33). Notably, the questions on frequency and intensity from Section A are similar to but less detailed than the frequency and intensity parts of the EXAS. Quality of performance is entirely absent from the EARS, whereas the EXAS collects no information on reasons for adherence behavior. When used complementarily, the EXAS and EARS provide detailed and extensive information on adherence to frequency, intensity, and quality of performance recommendations from a health-care professional, as well as on reasons for the adherence behavior reported by the patient. Strengths and limitations The first strength of this study is that it is the first to develop an instrument to measure adherence to frequency, intensity, and quality of performance of HBE recommendations in patients with LBP (15). During the development phase of the instrument, patients, physical therapists, and experts were involved, in accordance with the advice from Terwee et al. (2007) (34). In addition to development, the clinimetric properties of the instrument were also assessed. Using a measure with known validity and reliability provides a better understanding and interpretation of the findings when assessing adherence. As a result, clinicians are better able to tailor their treatments to individual patients. Researchers can use the EXAS to assess the effectiveness of HBE interventions and statistically control for
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