General discussion 175 physiotherapy practice. For a more comprehensive assessment of inter-rater reliability, multiple physiotherapy practices should be included. For the structural and construct validity, a diverse group of patients with COPD participated; patients from 53 different physiotherapy practices in both the Netherlands and Belgium. This diversity enhances the generalizability of the study results in other patients with COPD. As described in chapter 3 the RAdMAT-NL demonstrated good internal consistency reliability and evidence for the construct (convergent) validity of the questionnaire was indicated by medium to large significant positive correlations between the RAdMAT-NL subscale Participation and the other measures indicative of exercise adherence. Without the communication items the RAdMAT-NL can be used as a single measure of adherence. Granquist et al. [6] indicated in their study that all items loaded on one factor, however, they did not statistically examine whether there was actually unidimensionality. In that respect, it cannot be said that our study presented different results: the items of the RAdMAT-NL also loaded on one factor (all loadings > 0.46), however, the communication items do interfere with unidimensionality, which may have a number of causes. The first cause can be sought in the translation of the RAdMAT-NL; translation into a different language and different culture, a different patient group and a different setting can cause items to have a slightly different meaning (even though this has been taken into account in the transcultural translation by a native speaker). Second, Granquist et al. [6] also made their own observation regarding the communication items. Athletic trainers identified communication as an important factor for rehabilitation adherence, but literature did not identify communication as a rehabilitationadherence behavior [25]. Results of our study showed that physiotherapists indicated low scores on the communication items. Possibly this is because the communication items involve only the patient's communication; ‘asks questions about his/her treatment’, ‘communicates with the physiotherapist if there are problems with an exercise’, and ‘gives the physiotherapist feedback on the treatment program’. Possibly communication regarding adherence should focus much more on patient-therapist communication [26]. This type of communication affects patient adherence [26] and could add value in measuring adherence. Finally, the validation study was conducted during the COVID-19 pandemic and may have affected the way physiotherapists work. Because of the COVID-19 restrictions, physiotherapists kept more distance from their patients, had less time for them (patients could not stay in the practice to socialize because they had to leave for the next patient), so communication may have been different than without the COVID-19 restrictions. Recommendations for practice and research According to the participating physiotherapists the RAdMAT-NL is easy in use and proves to be a useful tool to determine whether or not their patients are adherent. According to the American College of Sports Medicine guidelines, a score of at
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