The primary result of this study yielded a German version of the non-compliance questionnaire. This will enable clinicians to evaluate the reasons behind the non-adherence of patients to physiotherapeutic care in Germany and German speaking countries. Using this tool will enable clinicians to develop strategies that aim at overcoming barriers of adherence to physical therapy.
The synthesis of a common forward translation proved to be challenging. While the translator of T1 tried to convey a cultural translation of the items, the T2 translator tried to provide a literal translation. Since putting the items in the context of a colloquially German-speaking community was deemed to have a higher priority (12).
The findings of the testing stage 5 revealed two main challenges. The first challenge came with the word to afford. Since the financial aspect was not clearly implied, one patients made a comment that the respective answer was based on the financial aspect of treatment. Another challenge was the discrimination between item 10 and item 11. Whilst item 10 suggest a total dependency on the physiotherapist, item 11 suggest that treatment directed by the physiotherapist is the most important aspect of rehabilitative care. Since despite being doubtful about the three items, all patients correctly interpreted the meaning correctly (as seen in the comment section) and the fact that the translation methodology concludes the step with the synthesis of the expert committee, no further changes were undertaken.
The most common problems with adherence seemed to be the excessive reliance on the physiotherapist. This goes on hand with previous research conducted on the topic (13). These results, however, are not representative and a conclusion cannot be made on the basis of these findings. This is due to the small sample size as well as other factors such as demographics (age range), geographical constraints (ward patients of the orthopaedics department) and diversity with regard to the musculoskeletal conditions (14).
Finally, a clear relationship between compliance with physiotherapy and better outcomes has not yet been established. The literature only provides grounds for that most patients are not active enough to maintain physical health (4). As well, clinical studies do not objectively quantify compliance as they relied on patient self-evaluation. Using this questionnaire, the authors of this paper will aim to identify the link between compliance, outcomes and mobile application-based rehabilitation.
Elements included in the resulting table of the study primarily based their findings on interviews with patients in ambulatory treatment in private practice in the Netherlands (7). Most of the elements can be included in our survey as they are representative of patient attitudes regardless of the setting, in which treatment takes place. However, our research will be performed using data from patients at the ward of the centre for orthopaedics and trauma surgery at a university clinic. The patients will have received a TKR and be bedridden immediately after surgery. Therefore, item four indicating the limited time of the patients will be removed. In addition, item seven referring to the affordability of the treatment will be omitted.
After conducting a literature review, items including inpatient-specific factors will be discussed after a literature review by a panel of experts and included as an extension to the translated items. These items might include the patient-physician relationship (15), factors related to the environment in which physiotherapy takes place (16) and patient demographics as well as familial support (4). A more detailed review of literature will be conducted. The resulting concepts will be brought together, arranged, prioritized and discussed by the group of specialists. The work of Ikart (2019) will be used to guide the expert review and pretesting of the synthesized questions (17).
In addition, aspects concerning the use of technology in guiding the rehabilitation of patients should be included to offer insight into the patient´s perspective. Since most patients with osteoarthritis are old, the usage of an app based program might prove challenging (18). Taking patient input into account will ensure the development of telerehabilitative methods that prove useful. Some improvements targeting the usability of mobile application by elderly were previously made (19). Other studies reviewed existing applications for rehabilitation after total knee and hip replacement and made recommendations for future mobile application design (20). After our randomized control trial, we hope to add further recommendations.
Comments stated by patients often were often out of focus with the questionnaire itself. These provided insight on attitudes and beliefs patients hold towards physical therapy. An example would be a comment stating that “physiotherapists can only do as much as teach the patients about the required exercises” and “that the burden of completing the exercises depends on the patients themselves”.
Limitations
The main limitation of this study was the contrast between the literal translation and the cultural translation. While some elements can be translated as is, yielding the same intended meaning, other elements proved to more challenging. This resulted in adopted words having a slightly different literal interpretation. However, the context in which they were put in, conveyed the meaning of the individual elements.