BACKGROUND:Clinical decision support systems (CDSSs) present a paradigm shift in health care by assisting complex decision-making processes. While implementing such systems has considerable potential, they simultaneously influence clinical encounters by impacting decision-making authority. SupportPrim PT (physiotherapy) is a CDSS that uses artificial intelligence methods to provide personalised treatment recommendations to patients with musculoskeletal disorders based on similar successful patients. This study aimed to explore how the CDSS influences the decision-making process of physiotherapists and patients. METHODS:This qualitative study is based on individual interviews with 11 patients with musculoskeletal disorders and 10 physiotherapists in Norwegian primary healthcare in 2021 who have used the SupportPrim PT CDSS. The interviews were analysed thematically, with a theoretical approach inspired by Actor-Network Theory. RESULTS:First, both patients and physiotherapists valued the visualisation of patients' biopsychosocial health status. It helped address health issues and expand and align perceptions of relevant information, leading to trust in physiotherapists' clinical reasoning. Nevertheless, revealing health problems also occasionally created insecurity. Second, the physiotherapists mainly felt that the CDSS treatment decision screen supported their reasoning. For some, it served as a pedagogic tool, lending the physiotherapist authority by confirming the accuracy of their treatment suggestions. However, many found it redundant to use with patients, as they felt secure in how to proceed. Patient involvement was also challenged by occasional inappropriate treatment suggestions and abundant and complex information, diminishing therapists' trust in the CDSS. CONCLUSION:CDSSs can prove valuable by cultivating trust in physiotherapists' clinical reasoning. However, this trust can simultaneously challenge shared decision-making with the patient. Other aspects influencing decision-making include expectations of the CDSS, its timing, and the content of treatment suggestions. The physiotherapists' ability and need to interpose between patients and the CDSS to counter inappropriate information also impede shared use. Future studies should investigate how such CDSSs can enhance patient agency by allowing access and addressing the changing role of the physiotherapist once a CDSS is introduced in the clinical encounter.

Background Cognitive Behavioural Therapy for Insomnia (CBT-I) is the recommended first-line treatment for insomnia. Group-delivered CBT-I has demonstrated varied effectiveness, prompting the need for further refinement of its content. This study aimed to revise a group-based CBT-I intervention in Norwegian primary care by integrating patient adherence data, feedback on therapy components, established best practices, and input from key stakeholders. Methods The study was conducted as a mixed-method process evaluation, including 69 responses to the Treatment Components Adherence Scale, and 11 interviews with group-delivered CBT-I participants. Quantitative data were analysed descriptively, and qualitative data were analysed using the Framework Method. The original group-delivered CBT-I consisted of four two-hour sessions in groups of 5 to 15 participants. The treatment was revised according to the principles of the Framework for Developing and Evaluating Complex Interventions. Results Nearly 80% of the participants adhered to sleep restriction most of the time or consistently, of which about half found the treatment component helpful and effective. In all, 72% adhered to cognitive restructuring elements, which participants found to be the most helpful CBT-I element. Practical factors were highlighted as the reason for highly variable adherence to stimulus control, which amounted to 31% for getting out of bed when unable to sleep, 83% for following fixed prescribed wake times, and 91% for bedroom-use guidelines. Interviews showed that participants found the course valuable, highlighting the focus on sleep quality and the group setting as particularly helpful. Still, components such as sleep restriction proved challenging, and several expressed a wish for individual follow-up and additional sessions. In the revised version of the group-delivered CBT-I, sleep restriction and stimulus control are introduced earlier, and treatment duration is extended by one session and three weeks to ensure longer and more thorough follow-up for those in need. Conclusions Greater emphasis on the behavioural CBT-I components, longer treatment duration, and more thorough practitioner follow-up to improve patient adherence were incorporated with the aim of further improving the effectiveness of the group-delivered CBT-I implemented in Norwegian primary care. The revision also considered existing resource constraints and the operational context of primary care delivery.

BackgroundSelf-management is endorsed in clinical practice guidelines for the care of musculoskeletal pain. In a randomized clinical trial, we tested the effectiveness of an artificial intelligence–based self-management app (selfBACK) as an adjunct to usual care for patients with low back and neck pain referred to specialist care. ObjectiveThis study is a process evaluation aiming to explore patients’ engagement and experiences with the selfBACK app and specialist health care practitioners’ views on adopting digital self-management tools in their clinical practice. MethodsApp usage analytics in the first 12 weeks were used to explore patients’ engagement with the SELFBACK app. Among the 99 patients allocated to the SELFBACK interventions, a purposive sample of 11 patients (aged 27-75 years, 8 female) was selected for semistructured individual interviews based on app usage. Two focus group interviews were conducted with specialist health care practitioners (n=9). Interviews were analyzed using thematic analysis. ResultsNearly one-third of patients never accessed the app, and one-third were low users. Three themes were identified from interviews with patients and health care practitioners: (1) overall impression of the app, where patients discussed the interface and content of the app, reported on usability issues, and described their app usage; (2) perceived value of the app, where patients and health care practitioners described the primary value of the app and its potential to supplement usual care; and (3) suggestions for future use, where patients and health care practitioners addressed aspects they believed would determine acceptance. ConclusionsAlthough the app’s uptake was relatively low, both patients and health care practitioners had a positive opinion about adopting an app-based self-management intervention for low back and neck pain as an add-on to usual care. Both described that the app could reassure patients by providing trustworthy information, thus empowering them to take actions on their own. Factors influencing app acceptance and engagement, such as content relevance, tailoring, trust, and usability properties, were identified. Trial RegistrationClinicalTrials.gov NCT04463043; https://clinicaltrials.gov/study/NCT04463043

BackgroundSupervisors play a pivotal role in the sick leave process. Although responsibility for sick leave and return to work follow-up is increasingly placed on the workplace in Norway, few studies have explored supervisors' experiences. This study aims to explore supervisors´ experiences with attending to employees' sick leave and return to work process.MethodsThis study consists of individual interviews with 11 supervisors from diverse workplaces that was analysed thematically.ResultsThe supervisors emphasised the value of presence at the workplace, the need for them to obtain information and uphold dialogue, considering individual and environmental influences on return-to-work and allocating responsibility. Investing time and money was crucial to prevent or reduce the negative impact of sick leave.ConclusionsThe supervisors' perception of attending to sick leave and return-to-work largely reflect Norwegian legislation. However, they find obtaining information and managing responsibility challenging, suggesting that their responsibilities for return-to-work are perhaps disproportionate to their knowledge on attending this process. Individualised support and guidance on how to develop accommodations based on the employee´s workability should be made available. The reciprocal nature of follow-up described also reveals how the return-to-work process is enmeshed with (inter)personal considerations possibly resulting in unequal treatment.

Background We have developed a clinical decision support system (CDSS) based on methods from artificial intelligence to support physiotherapists and patients in the decision-making process of managing musculoskeletal (MSK) pain disorders in primary care. The CDSS finds the most similar successful patients from the past to give treatment recommendations for a new patient. Using previous similar patients with successful outcomes to advise treatment moves management of MSK pain patients from one-size fits all recommendations to more individually tailored treatment. This study aimed to summarise the development and explore the acceptance and use of the CDSS for MSK pain patients. Methods This qualitative study was carried out in the Norwegian physiotherapy primary healthcare sector between October and November 2020, ahead of a randomised controlled trial. We included four physiotherapists and three of their patients, in total 12 patients, with musculoskeletal pain in the neck, shoulder, back, hip, knee or complex pain. We conducted semi-structured telephone interviews with all participants. The interviews were analysed using the Framework Method. Results Overall, both the physiotherapists and patients found the system acceptable and usable. Important findings from the analysis of the interviews were that the CDSS was valued as a preparatory and exploratory tool, facilitating the therapeutic relationship. However, the physiotherapists used the system mainly to support their previous and current practice rather than involving patients to a greater extent in decisions and learning from previous successful patients. Conclusions The CDSS was acceptable and usable to both the patients and physiotherapists. However, the system appeared not to considerably influence the physiotherapists' clinical reasoning and choice of treatment based on information from most similar successful patients. This could be due to a smaller than optimal number of previous patients in the CDSS or insufficient clinical implementation. Extensive training of physiotherapists should not be underestimated to build understanding and trust in CDSSs.

Background Insomnia is prevalent among patients receiving treatment for long-term musculoskeletal complaints in inpatient rehabilitation settings. Cognitive-behavioral therapy for insomnia (CBT-I) is effective for improving sleep quality in patients with pain, but a lack of therapists often limits the capacity to use this therapy in rehabilitation programs. The aim of this randomized clinical trial (RCT) is to evaluate the effectiveness of app-delivered CBT-I adjunct to inpatient multimodal rehabilitation for individuals with comorbid musculoskeletal complaints and insomnia, compared with rehabilitation (usual care) only. Methods This RCT has two parallel arms: 1) inpatient multimodal rehabilitation and 2) app-delivered CBT-I adjunct to inpatient multimodal rehabilitation. Patients referred to Unicare Helsefort (Norway) with long-term chronic musculoskeletal complaints are invited to the study. Eligible and consenting participants will be randomized to the intervention and usual care at a ratio of 2:1. Assessments will be carried out at baseline (prior to randomization), 6 weeks (at the end of rehabilitation), 3 months (primary outcome), as well as 6 and 12 months after the rehabilitation. The primary outcome is insomnia severity measured at 3 months. Secondary outcomes include pain intensity, health-related quality of life, fatigue, physical function, work ability, expectations about sick leave length, sick leave, and prescribed medication. Exploratory analyses are planned to identify moderators and mediators of the effect of the app-delivered intervention. Discussion This RCT will provide novel knowledge about the effectiveness of app-delivered CBT-I as an adjunct to usual care among patients participating in inpatient multimodal pain rehabilitation. Regardless of the results from this trial, the results will improve our understanding of the utility of dCBT-I in the field of rehabilitation and the importance of adding sleep therapy to this patient group. Trial Registration This trial was prospectively registered in ClinicalTrials.gov October 10, 2022 (ClinicalTrials.gov identifier: NCT05572697).

Purpose: Although it is believed that involving the workplace and stakeholders in return-to-work interventions is beneficial, Norwegian occupational rehabilitation programmes rarely do. During 2015-2016, Hysnes Rehabilitation Centre provided inpatient multimodal occupational rehabilitation, including workplace meetings with employees, supervisors, and rehabilitation therapists. This study aims to explore the meetings´ content and stakeholders´ experiences.Methods: This was a multiple case study including non-participant observation of workplace meetings and interviews with participantsResults: Essential features of meetings included revealing and aligning the employee's and supervisor's understandings. Three components seemed instrumental in developing shared understandings leading to appropriate adjustments: 1) disclosing causes of absence, 2) validating difficulties, attitudes, and efforts, and 3) delimiting responsibility. Therapists played a vital role in addressing these components, supporting employees, and ensuring planning of appropriate solutions.Conclusion: Developing shared understandings by addressing and aligning illness- and return-to-work representations appears important for return-to-work interventions. Although pivotal to developing appropriate adjustments, disclosure depends upon supervisors' display of understanding and should not be encouraged without knowledge of the employee´s work situation. How supervisors relate to employees and implement adjustments may be as important as the types of adjustments. The therapist's support and validation of employees in vulnerable situations also seem valuable.Trial registration: The trial is registered at clinicaltrials.gov (NCT02541890), 4 September 2015. https://clinicaltrials.gov/ct2/show/NCT02541890.

Background: Facilitating return to work can be challenging due to the complexity of work disability. Few studies have examined rehabilitation programs based on Acceptance and Commitment Therapy that intend to support return to work, and none have investigated therapists' experience with providing such programs. The aim of this study was therefore to explore therapists' experience of addressing the return to work process in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy. Methods: This was a qualitative interview study supported by participant observation. Therapists were interviewed regarding their experiences with addressing return to work in an inpatient occupational rehabilitation program based on Acceptance and Commitment Therapy. In addition, the rehabilitation program was investigated through participant observation. The interviews were analysed according to Interpretative Phenomenological Analysis and informed by an analysis of field notes from the participant observation. Results: Acceptance and Commitment Therapy was experienced as a meaningful approach to facilitate return to work, as it allowed therapists to address all relevant aspects of the individual participant's life that might influence work participation. The therapists' twofold goal was to support participants in building both a meaningful life and sustainable work participation. To do so, they attempted to instil long-term and interrelated processes concerning ownership, causes of sick leave, relation to expectations, the values of work, and the scope of agency. Conclusion: Unfolding values connected to work participation might reconcile the tension between work and family life by integrating work with other areas of life. Providing work participation with personal meaning also seems especially commensurable with a context where economy presents a poor incentive for return to work. Therapists should, however, be attentive to the need to secure the prominence of return to work by relating participants' chosen themes explicitly to their return to work process. Therapists should also be aware of the dilemma that may arise when they attempt to refrain from providing advice while simultaneously encouraging actions they consider appropriate to facilitate sustainable work participation. In addition, having an individual-oriented approach to occupational rehabilitation may obscure the extent to which return to work is a multistakeholder process.

Recent research has suggested that interventions at the workplace might be the most potent ingredient in return to work interventions, but few studies have investigated the different effects of workplace interventions as part of occupational rehabilitation programs. The comprehensive design described in this article includes effect (on return to work and health outcomes), and health economic evaluations of a workplace intervention added to a multicomponent rehabilitation program. Qualitative and mixed method studies will investigate sick-listed persons’, rehabilitation therapists’ and employers’ perspectives on the usability and outcomes of the rehabilitation program and the workplace intervention. The program and intervention are provided to patients with musculoskeletal, psychological or general and unspecified diagnoses. The program is multi-component and includes Acceptance and Commitment Therapy, physical exercise, patient education and creating a plan for increased work participation.