Self-efficacy and adherence to home exercises are fundamental to an effective treatment. Translating, culturally adapting, and evaluating the psychometric properties of a self-efficacy for home exercises scale will enable its use in clinical practice.
ObjectivesTo translate, culturally adapt, and evaluate the psychometric properties of the Self-Efficacy for Home Exercise Programs Scale (SEHEPS) in individuals with shoulder pain.
MethodsSEHEPS was translated from English to Brazilian Portuguese. Individuals aged 18 to 60 years with shoulder pain lasting at least 3 months were included. The test-retest reliability of the SEHEPS was verified through repeated applications by the same assessor. Construct validity was analyzed by correlation with the Chronic Pain Self-efficacy Scale (CPSS) and the Exercise Adherence Rating Scale (EARS). The responsiveness of the Brazilian Portuguese SEHEPS was assessed during a 12-week randomized clinical trial. The questionnaires were administered 4, 8, and 12 weeks after baseline.
ResultsThe Brazilian Portuguese SEHEPS demonstrated good reliability, with an intraclass correlation coefficient of 0.73 and Cronbach’s alpha of 0.93. Construct validity showed moderate correlations with CPSS (ρ = 0.45, p < 0.001) and EARS (ρ = 0.46, p < 0.001). Responsiveness analysis revealed that changes in SEHEPS scores were significantly correlated with CPSS scores (ρ = 0.42, p = 0.006), with an area under the curve (AUC) of 0.71. The tool showed no floor or ceiling effects.
ConclusionThe Brazilian Portuguese version of SEHEPS is a reliable, valid, and responsive instrument for assessing self-efficacy in home exercise programs among individuals with chronic shoulder pain.
Shoulder pain is considered the third most common musculoskeletal complaint1 and is a frequent cause of functional limitations and disabilities related to activities of daily living and work.2,3 The annual incidence of shoulder pain in primary care is estimated at 11.2 per 1000 individuals.4 Prevalence is 20 to 33 % in the general population5 and 45 % in workers performing repetitive movements.6 Conservative treatment is recommended for people with shoulder pain,7 and exercise therapy is effective in reducing pain and improving function.8,9 The prescription of home exercises is an important component of physical therapy treatment that is equally effective as supervised treatment.10 Home exercises can reduce resource costs, the need for frequent transportation to the place of care, and the demand on health professionals, making the service more accessible and overcoming the physical distance between the physical therapist and patient.
However, shoulder pain can be difficult to recover from, with improvement rates of only 24 % of patients after three months and 32 % after one year from the first episode of pain.11,12 Individuals with high levels of self-efficacy may respond better to treatment.13,14 Self-efficacy is defined as the "degree of personal belief in one's ability to perform specific tasks or behaviors to produce a certain outcome".15 Chester et al suggested that increasing self-efficacy could be effective in treating chronic shoulder pain, producing better outcomes after the rehabilitation period.13
The effectiveness of home exercises for treatment depends on good patient adherence to the prescribed program. Poor adherence can have a negative impact on clinical outcomes, increase treatment time, and increase costs.16 One of the factors that can lead to low adherence to home exercises is patients' low self-efficacy.17 Thus, low self-efficacy for performing home exercises can be an obstacle to effective treatment. Given the importance of measuring this clinical outcome, the Self-Efficacy for Home Exercise Programs Scale (SEHEPS) was developed18 based on the Self-Efficacy for Exercise and has 12 questions to be quickly completed.18 It is the only tool that specifically assesses self-efficacy for home exercise and can be used by clinicians to identify individuals at risk of nonadherence to home exercise programs.18
The original English version of the SEHEPS is reliable and valid for assessing exercise self-efficacy in individuals with musculoskeletal complaints and in individuals undergoing post-surgical treatment for orthopedic conditions.18 However, this scale has not yet been translated or culturally adapted for use in other languages, and its psychometric properties must be assessed to ensure cross-cultural equivalence.19 This study translated and adapted the SEHEPS into Brazilian Portuguese. The psychometric properties of the Brazilian Portuguese version of the SEHEPS in individuals with shoulder pain were also verified.
MethodsProceduresThe method of translation, cultural adaptation, and validation followed the recommendations of the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and previous studies,20–22 which is divided into translation, synthesis of translations, translation back into the original language (back-translation), expert committee analysis, and pre-testing. After this phase, the psychometric properties were assessed through validation and test-retest reliability.
The SEHEPS has 12 items that measure self-efficacy for performing home exercises. Each item is scored on a 7-point scale (0–6), with higher numbers indicating greater confidence. The total score (0–72) is obtained by adding up the scores of the 12 items.18 The questionnaire has been validated in English and has high internal consistency (α=0.96) and high test-retest reliability (ICC=0.88).18
Initial translationThe SEHEPS was translated into Portuguese by two Brazilian professional translators who were fluent in English. The first translator has a background in health sciences and was informed about the purpose of the research. The second translator did not know health sciences and was not informed about the concepts evaluated. The translators developed the two translations independently, which were compared and discussed by the authors of this study. Modifications were made to resolve disagreements and formulate the consensus version in Portuguese, maintaining the fundamental characteristics of the original questionnaire.
Back-translationThe consensus version in Portuguese was translated back into English by two native English-speaking professional translators, who were not informed of the purpose of the research and did not have access to the original questionnaire. The committee then met and discussed the differences between all the versions and the original questionnaire, modifying or eliminating irrelevant, inappropriate or ambiguous items, suggesting changes and checking for semantic equivalence (referring to the real meaning of the words), idiomatic equivalence (referring to the interpretation of colloquialisms), cultural equivalence (ensuring that the practices used in the instrument are common in the new culture where it will be applied) and conceptual equivalence (checking the cultural importance of the situations presented in the instrument). The committee comprised four physical therapists who are part of the research team, one of them with extensive experience in translation and cultural adaptation of instruments, and the four translators who participated in the translation and back-translation phase. All translators had experience translating instruments as part of research. The sentences were rewritten until a consensus was reached on a Portuguese version for the Pre-test (Pre-Final Version).
Pre-testThe Pre-final version of the SEHEPS was applied to 30 patients23 with shoulder pain to check their understanding and acceptability of the questions and answers. The patients reviewed the content, indicated whether they understood it, and provided comments on their interpretation. Items that did not reach a level of understanding >90 % by the volunteers were reformulated.24 With the results of the pre-test, the Final Version in Portuguese was formulated (Fig. 1).25
Participants
This study was conducted in parallel with individuals from a randomized controlled trial.26 All individuals were selected by a physical therapist who is a PhD student with six years of experience and a member of the research team, and also assessed the eligibility criteria. The inclusion criteria to participate were 18 to 60 years of age, a Numerical Pain Rating Scale (NPRS) of 3 points or greater in the anterolateral shoulder region at rest or during arm movement,27,28 and shoulder pain for at least 3 months.19,20 Individuals were not included if they had a history of trauma related to the onset of symptoms; history of clavicle, scapula or humerus fracture; history of surgical stabilization or rotator cuff repair; history of shoulder dislocation; pain related to the cervical spine; adhesive capsulitis; systemic disease involving the joints and cognitive impairments that prevented the completion of the questionnaires or participation in the intervention. After enrolment in the study, participants were excluded if they presented with fractures, surgeries, musculoskeletal or neurological injuries that prevented them from accessing treatment, or if they received corticosteroid injections during the treatment.
This study was approved by the Human Research Ethics Committee of the University (CAAE: 68,091,523.7.0000.5504). Informed consent was obtained from all participants before enrolment in the study. Research data, such as the full protocol, database, and statistical code, will be made available on request.
Assessment of measurement propertiesStructural validityThe structural validity of SEHEPS was assessed using exploratory factor analysis, as no previous study has investigated its structural validity. The exploratory factor analysis established which questionnaire items were contributing to a factor.29 The data were considered suitable for the exploratory factor analysis if it presented significant Bartlett’s test of sphericity (p < 0.05) and Kaiser-Meyer-Olkin test >0.6.30,31 The exploratory factor analysis was performed with a polychoric matrix, robust diagonally weighted least squares extraction method and robust promin rotation. The number of factors was determined using Catell’s scree test and parallel analysis. Items were retained in a factor if they showed a factor loading of at least 0.30. Items with a communality value below 0.40 were considered for deletion, as they indicated insufficient shared variance with other items.32
Construct validityThe hypothesis testing for the assessment of construct validity was based on the study that developed the SEHEPS.33 The original study observed a correlation of 0.71 between SEHEPS and the Self-Efficacy for Exercise Scale, which has not been translated and validated for the Brazilian population. In addition, the original version observed the association between SEHEPS and adherence to a 4-week home exercise program with rho=0.38. We defined two a priori hypotheses for construct validity. First, we expected a moderate to strong positive correlation between the SEHEPS and the Chronic Pain Self-Efficacy Scale (CPSS),34 as both scales assess the self-efficacy of individuals with musculoskeletal pain. Second, we expected a moderate to strong, significant positive correlation between the SEHEPS and the Exercise Adherence Rating Scale (EARS), as both instruments assess constructs related to self-management and behaviors toward home exercise.35 Construct validity was considered acceptable if both hypotheses were confirmed.
We used EARS as a comparator because the Self-Efficacy for Exercise (SEE) scale, used in the original SEHEPS validation, has not been translated for Brazilian Portuguese. The EARS assesses a related construct, adherence to home exercise, and is adapted and translated to the Brazilian context.35
ReliabilityReliability refers to the degree to which the instrument is free from measurement error.19 Test-retest reliability, internal consistency, and measurement error were used to analyze reliability. For the analysis of test-retest reliability, the SEHEPS was applied twice under similar conditions (same physical therapist and self-administered in a laboratory setting), with a mean interval of 48 h between applications. The interval between applications minimized the likelihood of changes in symptoms and recall.36 During this period, individuals did not receive any treatment or related instructions for home exercising and were waiting to be contacted by the research team to schedule their first physical therapy session. Therefore, no treatment occurred between assessments. Finally, the individuals were asked and confirmed that they did not receive any treatment during that period.
Internal consistency assesses the degree to which items within a questionnaire (or subscale) are interrelated with each other, indicating their homogeneity and ability to measure the same underlying concept.36,37 The measurement error was assessed with Minimal Detectable Change (MDC) and Standard Error of the Measurement (SEM).36 The SEM refers to the measurement error in the same unit as the measurement itself.36 The MDC represents the smallest change or difference that is distinguishable from measurement error and can be considered a true difference.19
InterpretabilityInterpretability refers to how easily one can attribute qualitative meaning, such as clinical or commonly understood connotations, to the quantitative scores or changes in scores of an instrument.37 The analysis of interpretability includes the presence of floor and ceiling effects.19 Floor and ceiling effects of the SEHEPS total score were considered present if a large part of the sample (>15 %) achieved scores at either the lower or upper end of the scale, respectively.38 Floor and ceiling effects may indicate limited content validity and reduce the responsiveness and sensitivity of the instrument to detect differences between groups.36
ResponsivenessResponsiveness refers to the ability of an instrument to detect changes over time in the construct to be measured.19 Responsiveness of SEHES was assessed in individuals who received eight weeks of treatment for shoulder pain based on exercises.
Outcome measuresChronic pain self-efficacy scaleThe Portuguese Brazilian version of the Chronic Pain Self-Efficacy Scale (CPSS) is a scale that assesses self-efficacy in individuals with chronic pain.39 The CPSS consists of 22 items divided into three domains: self-efficacy for pain control, self-efficacy for physical function, and self-efficacy for pain control. Each item is rated on a scale of 10 to 100 according to how sure you are about each item. The total score ranges from 30 to 300 points, with a higher score indicating greater self-efficacy. The Brazilian version of scale is valid and has high reliability with an intraclass correlation coefficient (ICC) of 0.94 for assessing patients with chronic pain.39
Exercise adherence rating scaleThe Portuguese Brazilian version of the Exercise Adherence Rating Scale (EARS) is a self-administered instrument to assess home exercise adherence.40 It consists of six items that assess adherence to the prescribed exercises (section B) and two complementary sections that assess the reasons for adherence or non-adherence in ten items (section C) and collects information on exercise recommendations (section A). Scoring is done on a scale of 0 (totally agree) to 4 (totally disagree) with a total score ranging from 0 to 64 among the items in sections B and C. Items with positively phrased sentences receive an inverted score.40 The Brazilian version of the scale showed good validity, responsiveness, and high reliability with an intraclass correlation coefficient of 0.91 in patients with non-specific low back pain.41
Global rating of changePatient satisfaction was assessed by the Global Rating of Change (GROC).42 The score varies by 15 points, with −7 being a very significant worsening, 0 no worsening or improvement, and +7 a very significant improvement.
Numerical pain rating scaleThe intensity of shoulder pain was assessed using the 11-point Numerical Pain Rating Scale. The scale is scored from 0 (no pain) to 10 (maximum pain), and is valid and highly reliable between days, with an intraclass correlation coefficient of 0.84 for assessing individuals with shoulder pain.43
Disabilities of the arm, shoulder and handThe Brazilian version of the DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire was used to assess the pain and upper limb function of the patients.44 The questionnaire contains 30 questions that include items related to physical function, symptoms, and social function. Each question has five possible answers ranging from "There was no difficulty" to "I couldn't do it" and is scored on a point scale from 1 to 5. The questionnaire score is calculated using a formula previously established in the literature. The score ranges from 0 to 100, where the higher the score, the more severe the disability.44–46 The minimum clinically important difference (MDCI) of DASH is 10.8 points.47 The Brazilian version has an inter-rater and intra-rater intraclass correlation coefficient of 0.93 and 0.99, respectively.44
Statistical analysisContinuous data were presented as mean (standard deviation) or median (first–third quartile). Data distribution was assessed with Kolmogorov-Smirnov and visual inspection of the histograms, which indicated the non-normal distribution of SEHEPS and CPSS. The association between the SEHEPS and CPSS was examined with Spearman's rank correlation coefficient. The correlation coefficient was interpreted as negligible (<0.10), weak (between 0.10 and 0.39), moderate (between 0.40 and 0.69), strong (between 0.70 and 0.89), and very strong (between 0.90 and 1.0).48
Test-retest reliability was evaluated using ICC(3,1) with values interpreted as follows: <0.50 as poor reliability, 0.50 to 0.75 as moderate, 0.75 to 0.90 as good and greater than 0.90 as excellent.49 Cronbach’s alpha was used to evaluate internal consistency, and it was considered adequate when greater than 0.70.36 The MDC was calculated using the formula MDC90= SEM x √2 × 1.64, and the SEM was calculated with the formula SEM=SD √1 – ICC.50,51 The floor and ceiling effects were analyzed with the frequency of the responses that achieved scores at either the lower or upper end of the scale, respectively.
Responsiveness was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC) and by analyzing the association between the change in SEHEPS scores from baseline to the 12-week treatment and the change in CPSS scores over the same period. A ROC curve was plotted based on the scores of GROC, which was considered an external anchor. The external anchor (GROC) classified the individuals into two categories: “importantly improved” or “slightly improved or not improved”, considering a cut-off of 4 points.52–54 The AUC and 95 % confidence interval were calculated using the change scores, and AUC greater than 0.70 was considered as adequate responsiveness.36,50,51,55 Level of significance was set at 0.05 and all statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS Inc, Chicago, IL) version 23.
ResultsThe characteristics of the individuals are presented in Table 1. All individuals reported that they understood the items during the pre-test phase, and no comprehension issues were identified. Although individual comprehension percentages were not recorded, overall feedback indicated that the translated version was well understood. No participants were excluded due to missing data. The SEHEPS was considered suitable for the exploratory factor analysis. The SEHEPS showed statistical significance on Bartlett’s sphericity test (p = 0.0001), and the Kaiser-Meyer-Olkin test was 0.91. The exploratory factor analysis suggested 1 factor (Fig. 2) that accounted for 74.92 % of total variance. All items presented communality greater than 0.4 (Table 2).
Characteristics of the individuals according to the analyzed measurement property.
Continuous data are reported as mean ± standard deviation. Categorical variables are presented as count and percentage. Abbreviations: DASH, Disabilities of the Arm, Shoulder, and Hand. Higher scores of Numerical Pain Rating Scale and DASH questionnaire indicate worse condition.
SEHEPS presented moderate reliability (ICC=0.73) and adequate internal consistency (Cronbach’s Alpha >0.7). SEHEPS did not present floor or ceiling effects (Table 3). The correlation analysis for construct validity showed that SEHEPS is moderately associated with CPSS (rho=0.45, p < 0.001) and EARS (rho=0.46, p < 0.001), confirming both a priori hypotheses and supporting its construct validity.
Reliability and internal consistency analysis of the Self-Efficacy for Home Exercise Programs Scale (n = 68).
| Variables | Median (Q1-Q3) | ICC (3,1) (95 % CI) | Cronbach’s Alpha | SEM | MDC90 | |||
|---|---|---|---|---|---|---|---|---|
| Test | Retest | Floor Effect, % | Ceiling Effect, % | |||||
| SEHEPS | 63 (56–69) | 59 (54–68) | 0.0 | 8.8 | 0.73 (0.59, 0.82) | 0.93 | 5.98 | 13.86 |
Abbreviations: CI, Confidence Interval; ICC, Intraclass Correlation Coefficient; MDC, Minimum Detectable Change; PCS, Pain Catastrophizing Scale; SEM, Standard Error of Measurement; Q1, first quartile (25th percentile); Q3, third quartile (75th percentile).
The results of responsiveness are described in Table 4. The change score of SEHEPS was moderately (rho=0.42) and significantly (p = 0.006) associated with a change in the score of CPSS. In addition, SEHEPS presented adequate AUC (> 0.7).
Responsiveness of self-efficacy for home exercise programs scale (n = 43).
| Variables | Mean (SD) of change score | Spearman's rank correlation coefficient | AUC (95 % CI) |
|---|---|---|---|
| CPSS | |||
| SEHEPS | 1.37 (14.42) | 0.42 | 0.71 |
Abbreviations: AUC, area under de curve; CPSS, Chronic Pain Self-Efficacy Scale, SD, Standard Deviation.
The present study translated and cross-culturally adapted the SEHEPS to Brazilian Portuguese and assessed its measurement properties. The findings support the applicability in clinical and research settings of the translated scale, demonstrating its reliability, validity, and responsiveness in a population of individuals with chronic shoulder pain. The psychosocial aspects of pain management, including self-efficacy, have an important role in determining the effectiveness of treatments in patients with shoulder pain.56,57 By quantifying self-efficacy for home exercises, the SEHEPS provides clinicians with information to address the psychosocial barriers and facilitators of their patients to perform prescribed exercises.
Construct validity was assessed by correlating SEHEPS scores with two other scales of similar constructs. CPSS and EARS assess self-efficacy, and treatment adherence, respectively.58,59 Low self-efficacy is associated with lower treatment adherence in individuals undergoing rehabilitation in various settings.60 Moderate correlations with both scales demonstrate that the SEHEPS measures self-efficacy to home exercises as a distinct but complementary construct related to rehabilitation. The findings highlight the importance of addressing self-efficacy for home exercises as an independent factor of adherence to rehabilitation programs and overall treatment engagement, as it is a factor not fully captured by broader self-efficacy scales or adherence scales.
The reliability analysis revealed good test-retest reproducibility, consistent with the findings from the original study, which found an ICC of 0.88,33 confirming the usefulness of the scale when applied in the population of individuals with shoulder pain. The internal consistency measured by Cronbach’s alpha was also considered adequate,61 further confirming that the items in the SEHEPS are homogeneous and measure a unidimensional construct, although lower than the values from the original study (α = 0.96).33 These psychometric properties establish the Brazilian Portuguese version of the SEHEPS as a reliable tool for assessing self-efficacy for home exercises in individuals with shoulder pain.
The SEM and MDC values found in this study were 5.98 and 13.86 points, respectively. Because the SEHEPS is scored on a 0–100 scale, the MDC represents approximately 14 % of the total score. This suggests that any change exceeding 13.86 points can be considered a true change in an individual’s self-efficacy for home exercises, above measurement error. Although the SEHEPS does not have an established Minimal Clinically Important Difference (MCID), a similar instrument, the Pain Self-Efficacy Questionnaire (PSEQ-10), has an estimated MCID of 9–14 % of the total score.62 In this context, the MDC observed for the SEHEPS appears clinically acceptable and consistent with instruments assessing similar constructs.
Responsiveness was evaluated over a 12-week treatment period. The changes observed in SEHEPS scores during the intervention were moderately associated with the changes in CPSS, confirming the tool's sensitivity to clinical changes and highlighting its utility for monitoring progress over time. This responsiveness is essential for both clinical practice and research, as it allows practitioners and investigators to detect meaningful changes in self-efficacy resulting from therapeutic interventions. Moreover, the absence of floor and ceiling effects in the SEHEPS suggests that the scale is well-calibrated to properly capture the range of self-efficacy levels,61 making it suitable for detecting changes in self-efficacy for home exercises. This psychometric property was not previously established for the SEHEPS scale.
Clinical implicationsThe SEHEPS allows physical therapists to assess and monitor self-efficacy for home exercise levels in individuals undergoing rehabilitation. Its sensitivity to change over a 12-week intervention period, as evidenced by responsiveness metrics, facilitates tracking the impact of therapeutic strategies. This capability aligns with the growing emphasis on patient-centred care, where understanding individual psychosocial factors is critical for tailoring interventions. The SEHEPS, by focusing specifically on self-efficacy for home exercises, addresses a key determinant of adherence. Future studies could explore the application of the SEHEPS in other musculoskeletal disorders where home exercise is a key component of treatment. Additionally, integrating SEHEPS findings with broader adherence strategies, such as goal-setting and patient education, may amplify its impact.
Moreover, by identifying individuals with low self-efficacy, clinicians can implement targeted strategies to enhance adherence to home exercise programs. Behavioral interventions, such as motivational interviewing or cognitive-behavioral techniques, could be incorporated to boost self-efficacy and, consequently, treatment outcomes.
Based on the distribution of SEHEPS scores in our sample (Q1 = 60, median = 63.5, Q3 = 67), we propose the following interpretative categories to support clinical use of the scale: low self-efficacy (0–60), moderate self-efficacy (61–66), and high self-efficacy (67–72. These ranges are based on the distribution of scores in our sample and may help clinicians identify individuals who may benefit from more support regarding home exercise.
Strengths and limitationsThis study adhered to COSMIN standards, ensuring the robustness of translation and validation processes. Additionally, the inclusion of responsiveness analysis through a 12-week intervention provides practical insights into the utility of the scale in both research and clinical settings.
The limitation of this study is that the sample was restricted to individuals with chronic shoulder pain who participated in a randomized controlled trial, limiting generalizability to other conditions or other clinical settings. Future research should investigate the measurement properties of the SEHEPS in other clinical populations, including individuals with different musculoskeletal conditions, and also assess its applicability in diverse cultural and linguistic contexts to enhance its generalizability. Another limitation is that although expert judgement was used during the cross-cultural adaptation process, a content validity analysis using the Content Validity Index (CVI) was not conducted and should be considered in future studies.
ConclusionThe Brazilian Portuguese version of the SEHEPS was developed through a translation and cross-cultural adaptation process. Based on the findings of this study, the Brazilian Portuguese SEHEPS is a reliable and valid tool for assessing self-efficacy for home exercises in individuals with shoulder pain.
Statement of the sources of grant supportVG was supported by grant #2022/08296–5São Paulo Research Foundation (FAPESP), by grant #131223/2019–4National Council for Scientific and Technological Development (CNPq), and the by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001. PRC is supported by grant #305444/2023–9CNPq Productivity Fellowship.
Ethics committee approval of the study protocolThis study was approved by the Human Research Ethics Committee of the Universidade Federal de São Carlos (CAAE: 68,091,523.7.0000.5504).
All authors declare that they have no competing financial interests or personal relationships that could have influenced the work reported in this paper.
