Decision support in the management of musculoskeletal disorders: a qualitative study of physiotherapists’ and patients’ experiences

Decision support in the management of musculoskeletal disorders: a qualitative study of physiotherapists’ and patients’ experiences | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Decision support in the management of musculoskeletal disorders: a qualitative study of physiotherapists’ and patients’ experiences Nina Elisabeth Klevanger, Anita Formo Bones, Ingebrigt Meisingset, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5181191/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 4 You are reading this latest preprint version Abstract 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 nested within a randomised controlled trial and is based on individual interviews with 11 patients with musculoskeletal disorders and 10 physiotherapists in Norwegian primary healthcare in 2021. 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. case-based reasoning data sovereignty clinical reasoning clinical autonomy BACKGROUND Clinical decision support systems (CDSSs) are increasingly used to assist in the complex decision-making processes of clinicians and patients and are described as a paradigm shift in present-day healthcare ( 1 ). Existing in various forms to suit a multiplicity of purposes, CDSSs generally pair individual patient characteristics to a computerised knowledge base and generate assessments and treatment recommendations through software algorithms ( 2 ). CDSSs have many benefits, such as providing diagnostic- and patient-facing decision support, increasing patient safety and clinical management ( 1 ), improving outcomes, and widening the scope of practice ( 3 ). However, they are also found to cause fragmented workflows and alert fatigue, depend on computer literacy, negatively impact user skills, require maintenance, and lack transportability and interoperability with other systems ( 1 ). In addition, healthcare personnel may find CDSSs insufficient to embed in practice and feel uncertain regarding their mechanics and skeptical of their ability to inform clinical decisions ( 3 ). A variety of factors influence the uptake of CDSSs. While most studies focus on usability ( 4 ), uptake is also found to be best predicted by context and implementation strategy ( 5 ). CDSSs are not merely computer technology; they are intimately connected to sets of practices contained by networks of actors situated in their specific contexts ( 6 ). The implementation of CDSSs is a process consisting of multiple stakeholders with varying perceptions ( 3 , 7 ). However, whereas healthcare personnel’s perspectives are well represented, the perspectives of other relevant actors, such as patients, are lacking, limiting the understanding and management of such CDSSs ( 3 ). Thus, it is necessary to gain knowledge of how they are used in various contexts and for various patient groups. Musculoskeletal (MSK) disorders are the leading cause of years lived with disability worldwide and represent a considerable burden to the individual and society ( 8 ). Clinical decision support tools for this patient group are rapidly expanding; however, inconsistent or preliminary findings with limited validity testing, effectiveness- and impact evaluation studies have been reported ( 9 – 13 ). The SupportPrim PT (physiotherapy) is a CDSS developed to provide biopsychosocial treatment suggestions for managing musculoskeletal pain disorders in primary care ( 14 ). The CDSS identifies similar successful patients and their treatment and aims to support the shared decision-making process of physiotherapists and patients. In physiotherapeutic care, shared decision-making can be defined as a process that “enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances” ( 15 ), p. 35. However, introducing CDSSs presents a paradigmatic shift from a dyadic relationship between the patient and the clinician into a triad, including the CDSS ( 16 ). Whereas CDSSs have been found to align agendas and empower patients to present their preferences more efficiently ( 3 ), they may also introduce several challenges in patient‒clinician interactions. For example, they can lead to changes in responsibility and decision-making authority ( 17 ), and some healthcare workers fear that professional autonomy will be reduced ( 4 ). A qualitative study exploring the development and acceptance of a preliminary version of the SupportPrim PT CDSS found that while it positively impacted the therapeutic relationship, patients were seldom included in treatment decisions ( 18 ). However, the study did not explore decision-making dynamics specifically, and the physiotherapists were not experienced in using the CDSS. Therefore, this study aims to explore how a CDSS providing personalised treatment support for MSK disorders influences the decision-making process of physiotherapists and patients. METHODS Study design and setting This qualitative study is based on individual interviews with physiotherapists and patients within Norway's primary healthcare sector using the SupportPrim PT CDSS in a randomized controlled trial registered with ISRCTN (ISRCTN17927832). In Norway, patients have direct access to physiotherapy in primary health care. The first consultation usually lasts 30–60 minutes, whereas the second consultation lasts between 20–30 minutes, and treatment commonly consists of a combination of education, exercises and passive modalities. The SupportPrim PT CDSS (hereafter referred to as `the CDSS´) was developed to improve healthcare management of common MSK disorders in primary physiotherapy care ( 14 ). Since these disorders are highly individual and influenced by a variety of biological, psychological, and social factors, the CDSS aims to account for patients' heterogeneity by providing personalised treatment. Using case-based reasoning ( 14 ), a problem-solving method in artificial intelligence, the CDSS identifies similar patients and their treatment, intending to help patients and physiotherapists decide on appropriate treatment through shared decision-making. The SupportPrim PT CDSS intervention was carried out as follows. The physiotherapists (hereafter referred to as `therapists´) received educational material and individual education on how to use it. Patients answered web-based questionnaires before attending their first consultation, and the answers were displayed on a patient profile screen ( appendix 1 ). The therapists could access this profile before the first consultation. The CDSS was designed for patients and therapists to explore together, before defining treatments goals. The therapists also needed to perform an examination and enter a diagnosis for the CDSS to identify the three most similar previous patients with successful outcomes, defined by a composite score of biopsychosocial domains ( 14 ). The patient and the three most similar patients were then displayed on a treatment decision screen ( appendix 2 ), which also included personalised treatment recommendations based on factors associated with high symptom severity (such as low physical or social activity, sleeping disorders, mental distress, poor workability, fear avoidance, low pain self-efficacy and low expectations of recovery). Detailed descriptions of the development and content of the CDSS are published elsewhere ( 14 , 18 ). Research participants and recruitment This study is based on a purposive sample of participants. Ten therapists and 11 patients who participated in the randomised controlled trial were recruited by email (therapists) or telephone (patients) by AFB or NEK for individual, semi-structured interviews conducted between April and June 2021. Therapists were primarily recruited based on their experience with using the CDSS, and we also aimed to include participants presenting a variety of sex, age, specialities, and clinical experience. PLEASE INSERT Table 1 HERE Table 1 Physiotherapist characteristics Number Age Sex* Speciality Clinical experience (years) CDSS use (no. of patients) 1 34 M General physiotherapy 15 12 2 29 M Physiotherapist with education in manual therapy 7 8 3 47 M General physiotherapy 24 8 4 44 F Physiotherapist with education in psychologically informed physiotherapy 21 11 5 38 F General physiotherapy 16 8 6 35 M Physiotherapist with education in manual therapy 10 12 7 41 M General physiotherapy 17 7 8 46 F General physiotherapy 18 14 9 42 F General physiotherapy 16 8 10 37 F General physiotherapy 12 14 *M = male, F = female The patients were consecutively recruited based on the number of patients with whom their therapist had used the CDSS. We chose to include patients whose therapists had used it with at least six patients. The interviews were conducted within two months of the first consultation. PLEASE INSERT Table 2 HERE Table 2 Patient characteristics Number Age Sex* Main problem Number of painsites Pain duration (months) 1 27 F Knee - 1–3 2 34 F Multisite/complex 7 6–12 3 29 F Neck 4 1–3 4 51 M Shoulder 4 > 12 5 47 F Hip 3 < 1 6 31 F Multisite/complex - 12 8 54 F Knee 3 6–12 9 28 M Back 1 > 12 10 25 F Multisite/complex 10 > 12 11 56 M Knee 1 1–3 *F = female, M = male The interview guide for the therapists included questions regarding their approach when using the CDSS, what they found valuable and challenging, what changes they had to make to ordinary practice, who they believed would benefit from using the CDSS and their perceptions of how patients experienced using it. The interviews increasingly focused on exploring the therapists' reasoning on how they used the CDSS with specific patients and chose not to use it with others. The interview guide for the patients included questions regarding their experiences with using the CDSS, for example, if the patient profile reflected their understanding of their health and how they felt about the therapists having access to it before the first consultation, the relevance of using similar patients to decide on treatment, what they found valuable and how the CDSS could be changed to better suit their needs. The interviews increasingly focused on exploring whether patients felt involved by their physiotherapists and how they interacted in using the various parts of the CDSS, especially when deciding on treatment. Data collection The participants were asked if they wanted to be interviewed by telephone or in a digital meeting since they resided in various parts of the country. All interviews lasted approximately 30–60 minutes, and the audio was recorded and transcribed verbatim. Either NEK or NEK and AB together performed the interviews, both of whom had previous experience conducting interviews. Theoretical approach Actor Network Theory ( 19 , 20 ) has inspired both the analysis and the discussion of the results. Viewing the social and technological dimensions as intimately entwined, the theory has been described as useful for exploring how technology shapes social processes ( 21 – 23 ). Actor Network Theory focuses on the interplay between technology and its users, seeing nonhuman elements as actors that can enable and mediate action by interacting with other actors. The reciprocal relationship between the technological and the social is further described by the term delegation ( 19 ), while we delegate work to technologies, technologies also delegate behaviour back into the social, influencing and shaping actions within sociotechnological networks. As such, the theory is not concerned with merely mapping interactions; it includes the process of translation ( 20 ) in which the actors define roles and delimit and negotiate the possibility of interaction and their margins of manoeuvre ( 20 ). In this study, Actor Network Theory is used as a framework to explore how patients and therapists interact with each other and with the CDSS and how these interactions influence the decision-making process. Analysis The interviews were analysed thematically ( 24 ), inspired by the Actor Network Theory perspectives on interaction ( 19 , 20 ). One researcher with a social science/public health research background (NEK) and three with physiotherapy and public health research backgrounds (FG, AB, IM) contributed to the analysis. NEK read all the interviews, noting initial thoughts on their content before coding them individually. FG and AB read and coded two interviews to compare interpretations. The interviews were coded inductively, paying particular attention to how the CDSS influenced experiences and interactions during the decision-making process. In line with the theoretical approach, we also attempted to identify occasions where the participants described how the CDSS influenced their thoughts, feelings, or actions through the following question: `What does the CDSS do and how ?´. As such, the themes are analytic abstractions of the participants' descriptions of how they experienced using the CDSS and what they believed it contributed to. NEK, FG and AB discussed the coding and preliminary themes before the first draft of the results. This draft was discussed with the remaining author IM, and in the further analytic process, the themes were adjusted into a chronological narrative based on how the CDSS was used. PLEASE INSERT Table 3 HERE Table 3 Coding tree Main themes, sub themes and quotes 1 Visualising health status ◦ Expanding and aligning perceptions of health issues - “We will perhaps talk about more than just the painful knee” ◦ Providing latitude to address health issues - “I find it a lot easier to point things out” ◦ Creating insecurity of prognosis - “It is perhaps almost a bit intimidating for those with many and complex issues” 2 Confirming treatment decisions ◦ Supporting clinical reasoning - “I feel that I get confirmation on doing a lot that others are doing too” ◦ Lending authority to therapists - “`That´s exactly what we agreed upon last time, then we know we are on the right track´” ◦ Demanding active management - “What factors does the system use to find these similar patients?” Quotes were selected to provide an interpretational context and exemplify or nuance the analytic text. Ethical considerations The Regional Committee for Medical and Health Research Ethics in Norway approved the study (49308/2020), and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki. Since the therapists and patients were not matched, the interviews with the therapists did not reveal the health information of identified patients. RESULTS From the interviews, we found that patients and therapists highly valued the visualisation of the patient's health status and that the therapists appreciated how the CDSS predominantly confirmed their treatment decisions. However, the CDSS also presented some challenges, and the patient interviews revealed that only two patients had used the treatment decision screen with the therapist, and six had not seen any screens. The following results expand on these findings. 1 Visualising health status Expanding and aligning perceptions of health issues Patients and therapists described the CDSS as enabling them to expand and align their views on relevant information about the patient's health issues and further treatment. Several patients believed that they would have revealed less information without the CDSS, either because they were unaware of the information’s relevance, would forget something, or because of their personality type: Otherwise, I don´t talk much about my life; I´m not the type that says much, no matter how painful things are. I don´t express it. (…) Therefore, the questions regarding sleep and such things were very accurate in my case because I struggle to sleep. (Patient 7) The therapists found that patients were primed into a psychosocial view of health and seemed more prepared by the first consultation due to answering the questionnaires. Some described this as improving the consultation flow and facilitating their work as a therapist: The patients are somewhat more prepared for what will happen—that we will perhaps talk about more than just the painful knee when they enter the door. And they have thought about the bigger picture and how it affects their life before they arrive. (Therapist 9) Although several therapists said that they retrieved similar information as displayed in the patient profile of the CDSS in their regular practice, most used several consultations to do so. Some therapists also said that the CDSS revealed information on topics they did not address in their regular anamnesis, either because of busy workdays or because attending to such topics felt unnatural. For example, one therapist had become attentive to how she often refrained from addressing psychosocial issues with some men and that the CDSS provided surprising information: “I am somewhat disappointed in how little I perhaps… Well, I believe patients communicate easily with me, and now I understand that if it wasn´t for this [CDSS], there are things I probably would have missed” (Therapist 8). As such, the CDSS revealed information that also reminded therapists to pay increased attention to psychosocial health aspects. Providing latitude to address health issues Both therapists and patients highly valued how the CDSS provided a thorough first impression of the patient's health status that helped address relevant issues. The patients predominantly felt that the patient profile reflected their health experience and gave therapists an improved impression of their situation. One patient described the visualisation in the CDSS as an objective representation of her health: “I liked it, truly - to have more perspective on it [my health situation], and it’s a good thing that others see it as well; it becomes a bit less subjective. It becomes like this: `Ok, here I can see that you have this and that´” (Patient 1). Some therapists also described how the CDSS provided a more authentic or accurate representation of health that facilitated their approach to patients: It is much easier to talk about a problem when you have the patient more or less statistically unfolded on the screen before you. I find it a lot easier to point things out because what is nice about that screen is that it says, for instance, if psychosocial challenges are showing red, it is much easier to talk to the patient about it and address the various themes. After all, the patients said it themselves, only in advance. (Therapist 3) As such, the CDSS was found valuable in granting therapists latitude to address aspects relevant to the patient's treatment. Viewing the screen together was described by several therapists as a valuable means to facilitate `the good conversation´ as it was disarming to patients compared with potentially uncomfortable or confrontative eye contact in regular consultations. The comprehensive information revealed by the CDSS also entailed that some therapists felt obliged to address the issues patients had reported. Although they predominantly seemed to find it useful, patients sometimes appeared surprised to have issues other than their main concern addressed: Last week, I had someone with poor mental health. But she was here because of a knee, so when I addressed it and said: `I can see this [in the CDSS]´, tears were running, and there was a conversation about it and a note to the general practitioner about it. Then, we continued to work on what we do. So that is one type of thing... I believe they answer the questions honestly, perhaps not thinking we will see it because some have seemed surprised that I have it [the information] once they arrive. (Therapist 8) Creating insecurity Although the interviews showed that patients commonly underlined the importance of addressing relevant health issues, it proved problematic for some. Not all felt comfortable completing the questionnaire or facing the therapist after providing sensitive information. One patient described the questionnaire as challenging since he expected questions regarding his mental health to appear; this was a sensitive topic, as he was feeling increasingly depressed owing to loss of function: Patient: I was a bit worried that I would be asked the question: `Do you want to commit suicide?´ Truly. Yes, it was a bit like: `When will the question come when they ask if I am in danger of committing suicide?´ (…) Interviewer: To enter her [the therapist’s] office when she had this information about you in advance, how did you experience that? Patient: Heh, it was intimidating. It was. And that was because of all those questions. (Patient 4) In this case, the patient described the therapist dealing explicitly with psychological issues before commencing physical treatment, something he found valuable despite his initial response to the questionnaire. Several therapists also believed that the visualisation of health information and prognosis potentially was disheartening for some patients, especially those with many complex and severe health issues. Therefore, most therapists underlined the necessity of viewing the patient profile before the first consultation, proceed with caution, and downplay the information to avoid alarming patients: I have experienced that it is perhaps almost a bit intimidating for those with many and complex issues. Especially this first picture where every arrow is red, it can be a bit… Well, I have been unsure to what extent I want to view it [with the patient] simply because it lights up red in every corner and looks dismal. (Therapist 8) One therapist also noted that being made aware of the high severity of symptoms before meeting the patient could negatively influence the therapists' assessments. While most patients underlined their awareness of their health issues beforehand, some described becoming increasingly attentive to their relevance or scope after having them visualised: I started to reflect more about my sleep because it… I do not believe I reflected upon answering that it was poor, but this system picked up moderate or medium sleep problems. So that was more evident to me; it was nice really. (…) I know that I sleep poorly sometimes, but when you see it crystal clear that you have sleep problems, then I find that it is perhaps something I should address or do more about. (Patient 1) In this case, the therapist merely mentioned the topic without addressing it further, which was something the patient did not react to since it was not the therapist’s area of expertise. However, one therapist also noted that comprehensive mapping and visualisation of health issues could lead to overtreatment of patients, who, on their part, are satisfied with merely a few tips to resolve a specific health issue. Having to attend to sensitive information they felt unable to manage themselves was also described as challenging by some therapists. In particular, those practising in areas with high pressure on health services, in rural areas with few referral opportunities, or with patients betwixt and between specialists found it troublesome, as they felt left with attending to the patient's issues themselves: The challenge is, to whom can I refer? These kinds of patients fall between all chairs—not severe enough to enter the community-based mental healthcare centres and not serious or specific enough for any special department. (Therapist 2) Most therapists and patients still underlined that, although it could initially create insecurity, providing relevant information was beneficial, as it provided an opportunity to address key factors in treatment. When asked what they believed revealing such comprehensive information contributed to, one therapist replied: “probably to a better comprehension of the fuller picture, of the life situation, how the pain and function problematics affect the life situation, and it probably also enables me to use the right treatment tools” (Therapist 7). 2 Confirming treatment decisions Supporting therapist reasoning When explaining what they believed a decision support system entailed in this setting, the therapists commonly underlined that the role of the CDSS was to support them in deciding on appropriate treatment. Although a few therapists described utilising some treatment suggestions from the CDSS in addition to their own, most said it supported already planned treatment. For some, this was particularly valuable due to the context of their practice: I use it as a support, a backing actor in a way. And to me, who is without colleagues, situated alone in the outback, it is worth its weight in gold (laughing). (…) I feel that I get confirmation on doing a lot that others are doing too, and you might get some useful suggestions as well, things you might pick up on. (Therapist 4) Although involving patients was commonly described as an essential means to provide more ownership of the treatment process later on, the therapists usually referred to patients as `more active than usual´ in relation to the patient profile, i.e., in providing information and discussing their situation. Few referred to the CDSS as enabling a process of shared decision-making regarding treatment, and some therapists described that not all patients should be included if the therapist felt secure in their treatment choice. The interviews with the patients mirrored the therapists' description in that most felt very much included in the consultations and valued being active while happily leaving the task of deciding on treatment to the therapist, trusting that s/he knew best: “I was like: `Just give me exercises I can do or give me a plan, and I will follow it´. I was very open since I had no understanding of why I was in pain. (...) I do not have the knowledge about that, and then I trust those who know more” (Patient 1). However, some therapists also underlined the need to ensure that the discrepancy between the patient's wishes and what they considered appropriate treatment was not too large to maintain trust in the relationship. Therefore, some would occasionally provide treatment that they found unnecessary. Lending authority to therapists In addition to providing therapists with confidence in their reasoning, several therapists also spoke of actively using information from the CDSS's treatment decision screen as a pedagogic tool. They would then show the patients the screen if it confirmed their treatment plans: When you look at similar patients, we look together at what treatment the patients found useful, and then you can: ´Well, that´s exactly what we agreed upon last time, then we know we are on the right track´. It is somewhat of a confirmation tool almost (laughs), you know, it is very useful in the instances when [the patient] needs some motivation—to be able to pull it [the CDSS] out in the second run to confirm that what I had figured out, it turned out to be very good! (Laughs). (Therapist 3) Some also described that the CDSS enabled them to build trust and reason with or persuade patients about the treatment choice. In line with the patient's descriptions of the CDSS as a more objective representation of their health, several therapists found it useful since it helped in determining or confirming what is `true´: “a nice thing about this system is that you get a clarification of what is true, right, it isn´t just me, I have backing on what I am saying. I believe that is important” (Therapist 6). As such, the CDSS can be said to lend the therapist authority—if their suggested treatment aligned with the CDSS. In addition, several therapists spoke of reviewing the graphs that explained progression over time as an aid in normalising pain and building motivation owing to the clear visualisation of progress: I think it is easier to get patients who are not that motivated to work out and do physical exercises and all that to budge some more when you have these visible graphs and pictures to showcase; it is somewhat easier to motivate them and: `Look at this!´ (…) Then, they can see that the pain graph usually increases some in the beginning and then declines. (Therapist 4) The trajectories were often used in the following consultations to reassure patients, for instance, if they did not experience pain reduction after starting treatment. Demanding active management Although the therapists described the treatment suggestions mainly as valuable confirmations, they occasionally found them inappropriate and deviating from their clinical reasoning. In addition, the information in the treatment decision screen was considered abundant and often too complex for patients. Therefore, therapists had to manage this part actively - if they chose to show it to patients. If the therapists found that the patients identified as similar by the CDSS were inappropriate, they sometimes questioned the CDSS’s algorithms: “What factors does the system use to find these similar patients? What are they comparing? Sometimes it is very evident, other times I am thinking: `these patients are just entered randomly and doesn´t fit at all´” (Therapist 9). Most therapists explained their low level of trust in the CDSS’s suggestion of similar patients because of the low number of patients included in the patient pool, and when encountering dissimilar suggestions, most told of not showing them to the patients. In other cases, seemingly similar patients had unsuitable treatment suggestions. For example, one therapist noted how suggestions for patients diagnosed with chronic fatigue syndrome were sometimes contraindicated owing to the amount of activity suggested. Some therapists also experienced that the CDSS suggested treatment supporting patients' biomechanical view of health or wish for passive treatment: When I have finished the patient profile, finished the examination and set a goal and that part [of the CDSS], I already have a fairly clear idea of where I want to go next. (…) We have perhaps started talking about a plan, using more active management strategies, exercises and have a comprehension of how to handle the pain. And then , when we open the part with similar patients, and it describes that it is very useful to receive stretching and passive treatment (laughs). When I see that, I do not want to open that door when we have already started moving in another direction. (Therapist 2) This quote also exemplifies how many therapists found the patient profile sufficient to set a treatment course after the first consultation, and as such, the treatment decision screen could prove disruptive to practice flow if suggestions diverged. Most therapists told of waiting to use this screen until the second consultation because of the additional time used to review the patient profile, insecurity in similar patients’ treatment suggestions, and the overall complexity of this part of the CDSS. In contrast to the simplicity of the patient profile, the treatment decision screen was experienced as more challenging to use due to the need for thorough explanations. Although most therapists felt knowledgeable in using the CDSS after 3–4 patients, some experienced that they still did not know how to utilise this part of the CDSS optimally after ten or more patients and that it sometimes was best to refrain from showing it to the patients altogether to avoid insecurity. DISCUSSION This is the first study to explore therapists’ and patients’ experiences with using a CDSS based on case-based reasoning that provides personalised treatment suggestions for MSK disorders. We found that patients and therapists valued the visualisation of health status, as it gave them latitude to address relevant health aspects and align views, although it occasionally created some insecurity. The therapists felt supported by the CDSS since the treatment decision screen predominantly reflected their clinical reasoning, and they sometimes used it to lend authority towards patients. However, the CDSS also contained complex information and, occasionally, inappropriate treatment suggestions, leading therapists to examine it in advance and carefully select which information to share with patients. The lack of patient involvement was also reflected in the patient interviews, revealing that very few had seen the treatment decision screen. The dynamics of the decision-making process Whereas previous studies have found that CDSSs can facilitate shared decision-making ( 3 , 25 ), the present study shed light on how and why therapists may also adjust patient involvement relative to the perceived appropriateness of CDSS information. The findings largely align with previous research on the SupportPrim PT CDSS, where patients and therapists were found to value it as a preparatory and exploratory tool positively impacting the therapeutic relationship, whereas treatment suggestions mainly supported ordinary practice instead of involving patients ( 18 ). Whereas the lack of user experience could explain the low involvement of patients in the former study, the present study reveals that therapists who are more experienced with the CDSS often chose not to do so as well. Inspired by the Actor Network Theory concept of translation , a process "during which the identity of actors, the possibility of interaction and the margins of manoeuvre are negotiated and delimited" ( 20 ), p. 201, the following discussion explores how the three main actors (the CDSS, therapists, and patients) influence and delimit the actions of one another at different time points of the decision-making process. We elaborate on these dynamics according to the two main parts of the CDSS: 1) the patient profile in which the patient's health problem is defined and 2) the treatment decision screen where treatment is suggested. 1) Defining the problem The results suggest that the CDSS plays an important role in shaping the views of the patient's health problem, severity, and prognosis. The CDSS can be said to delegate ( 20 ) the behaviour of the other actors by determining topics in the questionnaire, transforming the answers through inherent cut-offs to be visualised in the patient profile, and further determining what to address. A main finding is that thorough patient mapping and shared viewing of the patient profile increases trust - both the patients' trust in the therapists and the therapists' trust in their own reasoning. Decision-making has previously been described as including the role of patient illness narratives and subjective symptoms in relation to the CDSS's information ( 25 ). In a study by Barken et al. (2017), nurses frequently overrode system decisions since the CDSS was found inadequate to structure or provide sufficient clinical information, whereas the therapists in the present study found that the CDSS´s thorough patient information reflected patients and exceeded their regular anamnesis. Feeling more confident at an early point in the treatment process, several described the patient profile as sufficient to decide on treatment, thus underlining that the CDSS can have contributed to changes in practice, even if the subsequent comparison with similar patients did not produce novel insights. Although the patients and therapists appreciated how the visualisation of patients' health status in the patient profile provided a comprehensive view to decide on appropriate treatment, some expressed concerns regarding its scope, as it occasionally included more information than expected. It has previously been pointed out that employing CDSSs with vast technological options might deviate from dealing with the patient's concerns by conveying secondary findings ( 26 ). In the present study, patients seeking specific advice for a recent knee injury could, for example, find themselves discussing mental health issues in their first consultation. The ethical aspects of having physicians deal with issues outside the scope of their competency when using CDSSs have previously been linked to medicalisation ( 26 ). Reflecting this perspective, some therapists believed patients could become aware of and worry about health issues they would otherwise handle well, and that addressing psychosocial problems could be challenging for therapists, potentially leading to overtreatment. In addition, some expressed concern about the limited access to psychologists and physiotherapists with education in psychologically informed physiotherapy. A previous study on Norwegian physiotherapists found that although they had a multidimensional perspective on low back pain, they also believed that integrating psychosocial domains depends on clinical experience and that some demands may lie outside their professional competence ( 27 ). Given the authority ascribed to the CDSS by patients and therapists in the present study, i.e., referring to the information as more `objective´ or `true´, education on addressing and managing the potentially sensitive information the CDSS reveals is essential and should be done with caution. 2) Deciding treatment Although the patient profile seems to increase trust and patient involvement, this appears to negatively impact the intended use of the treatment decision screen, as few patients have seen it. We identified several aspects that influence the dynamics of the decision-making process and may explain why treatment was not decided as intended. First, patients’ and therapists’ expectations of the CDSS and each other's roles seem to influence use dynamics. Most therapists interpreted `decision support´ as the CDSS's role in supporting their own decision-making process with various degrees of patient involvement, suggesting that the terminology proves misleading and/or that education on the intentional use of the CDSS is insufficient. Describing involvement as `high´ can further reflect the relativity of `being involved in decision-making´, as most patients were involved more than expected in discussing their health issues. This finding also suggests that defining a patient's health issue is perceived as an essential part of the decision-making process. The trust in therapists as best suited to decide treatment and patients neither expecting nor wanting further involvement depends on the trust cultivated from reviewing the information in the patient profile and the alignment between the therapists' and the CDSS's treatment suggestions. A previous study has underlined that while patients may expect improved care from CDSSs, they simultaneously want to keep clinicians in the decision-making loop due to their clinical experience and ability to evaluate the CDSS outputs ( 28 ). While shared decision-making entails the patient's right to participate to the extent that they want when decisions regarding their healthcare are made ( 29 ), future studies should ensure that all participants receive sufficient information and education on the intention and potential use of the CDSS. The CDSS generated treatment suggestions based on similar patients intending to have the therapist and patient discuss its relevance further and did not explicitly include the patient's values and preferences. This could lead to `computer paternalism´ ( 26 ) (or `CDSS-paternalism´), undermining the patient's autonomy and authority over their treatment if the therapist chooses not to integrate these aspects in decision-making. While patients’ values, preferences and circumstances are important components of shared decision-making ( 15 ), dynamic variables such as human behaviours and environmental factors are seldom incorporated into CDSS algorithms ( 30 ). Therefore, therapists need to consider the broader context of the patient–therapist–CDSS encounter when delimiting what constitutes appropriate treatment when applying a CDSS in this setting. It should also be noted that patients attending physiotherapy for low back pain in Norway initially expect exercises and a body-oriented diagnosis, whereas their view of pain and management shifts towards a more biopsychosocial perspective after being in treatment ( 31 ). The current study suggests that a CDSS with a biopsychosocial orientation might help therapists facilitate this change in perspective earlier, which may also have positive implications for treatment adherence. Second, the timing and content of treatment suggestions appear to reduce the relevance of the CDSS for deciding treatment. Many therapists found the information from the patient profile sufficient to start treatment. While the treatment decision screen also proved too time-consuming to include in the first consultation, reviewing it in the second disrupted the natural progression of the decision-making process for some. This is an important challenge since CDSSs that provide decision support at the time and location of decision-making succeed better than others ( 32 ). In addition, treatment recommendations mostly confirmed the therapists' reasoning, suggesting that the CDSS's content and algorithms aligned with already established practices, i.e., presenting a logic of continuation rather than disruption or change ( 33 ), which was the system's intention. As such, the present CDSS's treatment suggestions seem to contain information of limited use, leading therapists to cherry-pick already familiar treatments instead of being provided novel plug-and-play suggestions to test. Previous studies have emphasised how innovations positively impacting clinical routines by making sense or adding meaning are more likely to succeed ( 34 ). Taken together, this CDSS’s relevance in deciding treatment based on similar patients and personalised treatment recommendations is not evident. Third, yet perhaps most important, patient involvement in shared decision-making is hindered by the therapist’s ability and need to interpose between the CDSS and the patient. While the CDSS has the potential to question the therapist’s reasoning when viewed together with the patient, this is inhibited by the therapist being an obligatory passage point ( 20 ). As such, they may either distance patients by rejecting the CDSS´s relevancy or transform components of the CDSS into active support by bringing them into the decision-making process as validation of their clinical reasoning, i.e., having the CDSS lend them authority. Whereas this may result in valuable trust in the therapist and present a means to build patient motivation, it simultaneously appears to be a mechanism reducing patients' agency by not granting them full access. The absence of transparency in system architecture and output explainability can lead to challenges in evaluating the significance, quality, and implications of the CDSS outputs, and since clinicians' understanding of such systems exceeds that of patients', it has implications for "the ability to exercise well-informed agency in the context of shared clinical decision-making" ( 28 ), p. 4. This asymmetric agency caused by differences in competence and access enables the therapists in the present study to use the CDSS as a source of authority, ensuring that their treatment suggestions appear valid. Liberati and colleagues ( 4 ) identified clinicians' fear of losing control over autonomous decision-making and having their clinical autonomy reduced by providing nonmedical expert authority to judge medical decisions as the most severe barrier to CDSS uptake. Others have also noted how CDSSs can influence expectations, verdicts, roles, and responsibilities, thus altering clinicians' decisional authority ( 28 ). In the present study, some of these concerns might have led therapists to avoid using treatment suggestions from similar patients in the intended way. However, the abundant and complex information in the CDSS also causes interpretative flexibility, requiring therapists to act as interposers. As such, a reason for not using the CDSS could also be that therapists are experienced in using the system, finding it redundant for those with acute and specific conditions and presenting unnecessary insecurity if the patient´s situation is severe or inappropriate treatment is suggested. The value of individual data sovereignty, where patients are provided the right to exercise informational self-determination by co-managing their data, has previously been highlighted regarding CDSSs ( 28 ). Whereas such access could enhance shared decision-making in the present study, it will also leave therapists unable to screen inappropriate information, emphasising the need to ensure its quality and relevance. The excessive and occasionally inappropriate information thought by therapists to cause insecurity in the present study should be addressed, as it significantly influences the intended use of the CDSS. Since the introduction of CDSSs creates new conditions for the roles of and interaction between patients and therapists in the decision-making process, therapists should also be guided on how to handle the challenges and utilise the benefits such systems present in clinical encounters. Strengths and limitations This study contributes valuable information on the mechanisms of using a CDSS, i.e., how various aspects of a system might be experienced as valuable by users while still undermining its intention. The authors represent various backgrounds, and the study results have been presented and discussed in research groups consisting of participants with knowledge of both the topic, patient group and methodology. Whereas authors IM, FG and AB developed and implemented the system, the first author, NEK, contributed to the system's evaluation process. Physiotherapists with various specialties participated in the study. While the findings suggest some variation between the experiences of the physiotherapist with education in psychologically informed physiotherapy and the others, we chose not to investigate this further because of only one recruited therapist with such education. The patients' interviews did not provide sufficient knowledge to investigate their experiences with the treatment decision screen in detail, and the results lean heavily on the therapists’ experiences with this part of the CDSS. However, the low number of patients familiar with this part of the CDSS also represents a key finding of the study, and the therapist interviews provided valuable insights into their reasoning for not including patients when using it. Notably, the lack of active use on the part of the patients does not necessarily mean that the CDSS was not used in the consultations since the therapists nevertheless found it useful when deciding on treatment. The majority of the interviews were conducted by telephone, possibly omitting important nonverbal information. Focus group discussions with therapists could also have yielded further information on their perceptions and reasoning for system use, and observational studies could have provided valuable information on the interaction between the actors and how the therapists differentiated their use according to specific patient characteristics. Future studies would benefit from such methodological triangulation. CONCLUSION The results of this study provide insight into the dynamics of the decision-making process between physiotherapists and patients when using a CDSS to decide on treatment for MSK disorders. Expanding and aligning views on patients’ health issues may cultivate trust in the therapist's clinical reasoning, and a CDSS can prove valuable in deciding on appropriate treatment early in the treatment process. However, this trust may simultaneously challenge shared decision-making. Other aspects that may influence the dynamics of the decision-making process include expectations of the CDSS and the other actors´ roles, as well as the timing and content of the CDSS. Furthermore, therapists' ability and need to interpose between patients and the CDSS can reduce patients' agency, and a lack of joint access allows the CDSS to be used to lend therapists authority instead of enabling shared decision-making. Future studies should investigate how CDSSs can enhance patient agency by providing access and how physiotherapists' role changes once tools influencing patient interaction and decision-making are introduced to clinical encounters. Abbreviations CDSS clinical decision support system MSK musculoskeletal PT physiotherapy Declarations Ethics approval and consent to participate This study was approved by the Regional Committee for Medical and Health Research Ethics in Norway (49308/2020), and all patients provided written informed consent before participation. Clinical trial number: not applicable. Consent for publication Consent for publication can be made available upon request from the journal. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available since the study participants’ consent did not include such permission. However, they are available from the corresponding author upon reasonable request and with the permission of the study participants. Competing interests The authors declare that they have no competing interests. Funding The project was funded by the Norwegian Research Council (ref. nr: 303331). Authors' contributions NEK designed the study; collected, analysed and interpreted the data; and wrote and completed the manuscript. FG designed the study, contributed to the analysis and interpretation of the data, and was a major contributor to the writing and completion of the manuscript. AB designed the study, collected the data, contributed to the analysis and interpretation of the data, and in writing the manuscript. IM designed the study and contributed to the interpretation of the data and writing of the manuscript. Acknowledgements We want to thank all the participants for contributing their time and experiences with using the SupportPrim PT CDSS. We also wish to express our deepest gratitude to Professor Ottar Vasseljen, who passed away on January 19 th 2024, for his significant contributions, including the conception of the various SupportPrim CDSSs, for leading the project group in developing the CDSSs and for his involvement in the present study. 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Building therapeutic alliances with patients in treatment for low back pain: A focus group study. Physiother Res Int. 2022;27(1):e1932. Braun M, Hummel P, Beck S, Dabrock P. Primer on an ethics of AI-based decision support systems in the clinic. J Med Ethics. 2020;47(12):e3. Hoffmann T, Bakhit M, Michaleff Z. Shared decision making and physical therapy: What, when, how, and why? Braz J Phys Ther. 2022;26(1):100382. Ulloa M, Rothrock B, Ahmad FS, Jacobs M. Invisible clinical labor driving the successful integration of AI in healthcare. Front Comput Sci. 2022;4. Unsgaard-Tøndel M, Søderstrøm S. Therapeutic Alliance: Patients' Expectations Before and Experiences After Physical Therapy for Low Back Pain-A Qualitative Study With 6-Month Follow-Up. Phys Ther. 2021;101(11). Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330(7494):765. Torenholt R, Langstrup H. Between a logic of disruption and a logic of continuation: Negotiating the legitimacy of algorithms used in automated clinical decision-making. Health. 2021;27(1):41–59. Sanders T, Nio Ong B, Sowden G, Foster N. Implementing change in physiotherapy: professions, contexts and interventions. J Health Organ Manag. 2014;28(1):96–114. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 07 Oct, 2024 Editor assigned by journal 05 Oct, 2024 Submission checks completed at journal 05 Oct, 2024 First submitted to journal 30 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5181191","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":363245110,"identity":"81ebd9d1-669d-413a-9da3-164615e721c5","order_by":0,"name":"Nina Elisabeth Klevanger","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYDACZhBxwALGtSFaiwSMm8bAQ5xVCC2HCWsxZ+c9+IHhjIScwfGzh1983HM+z166x4C5oAK3FstmvmQJhhsSxgZn8tIsZzy7Xcwjc8aAecYZ3FoMDvMYSDB8kEic2ZBjZsxz4HZij0SOATNvG14txj+AWupn9r8xM/5z4BxRWsxADkvgl8gxfsxw4ABxWiwSzkgY9ku8MWPsOZCc2HMjreAwDz6/nD9jfOPDMRt5Nv4c4w8/Dtglts9I3viYB0+IgUEChGKDx84BAhrggPkDsSpHwSgYBaNgZAEAY7RN8krMzrYAAAAASUVORK5CYII=","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Nina","middleName":"Elisabeth","lastName":"Klevanger","suffix":""},{"id":363245111,"identity":"34d8f612-73c1-4917-96b2-32de88a6c620","order_by":1,"name":"Anita Formo Bones","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"Formo","lastName":"Bones","suffix":""},{"id":363245112,"identity":"44ada689-f5d0-4b0b-b3de-e31f049fb804","order_by":2,"name":"Ingebrigt Meisingset","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Ingebrigt","middleName":"","lastName":"Meisingset","suffix":""},{"id":363245113,"identity":"a720d8b6-4321-480f-af8a-1b4b37ff9adc","order_by":3,"name":"Fredrik Granviken","email":"","orcid":"","institution":"Norwegian University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Fredrik","middleName":"","lastName":"Granviken","suffix":""}],"badges":[],"createdAt":"2024-09-30 13:23:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5181191/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5181191/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69339858,"identity":"37b30c4b-7f21-4be6-a3fc-8f7110e7c4fd","added_by":"auto","created_at":"2024-11-19 10:53:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":672378,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5181191/v1/672e7598-e7a1-45e7-a9cd-8fe04e7158c2.pdf"},{"id":69339391,"identity":"eade1b00-3a4b-4395-8417-a7efc6874724","added_by":"auto","created_at":"2024-11-19 10:45:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":344807,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-5181191/v1/3050ed64231b7a4fc8cbb1f0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Decision support in the management of musculoskeletal disorders: a qualitative study of physiotherapists’ and patients’ experiences","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eClinical decision support systems (CDSSs) are increasingly used to assist in the complex decision-making processes of clinicians and patients and are described as a paradigm shift in present-day healthcare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Existing in various forms to suit a multiplicity of purposes, CDSSs generally pair individual patient characteristics to a computerised knowledge base and generate assessments and treatment recommendations through software algorithms (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). CDSSs have many benefits, such as providing diagnostic- and patient-facing decision support, increasing patient safety and clinical management (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), improving outcomes, and widening the scope of practice (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). However, they are also found to cause fragmented workflows and alert fatigue, depend on computer literacy, negatively impact user skills, require maintenance, and lack transportability and interoperability with other systems (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In addition, healthcare personnel may find CDSSs insufficient to embed in practice and feel uncertain regarding their mechanics and skeptical of their ability to inform clinical decisions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA variety of factors influence the uptake of CDSSs. While most studies focus on usability (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), uptake is also found to be best predicted by context and implementation strategy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). CDSSs are not merely computer technology; they are intimately connected to sets of practices contained by networks of actors situated in their specific contexts (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The implementation of CDSSs is a process consisting of multiple stakeholders with varying perceptions (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, whereas healthcare personnel\u0026rsquo;s perspectives are well represented, the perspectives of other relevant actors, such as patients, are lacking, limiting the understanding and management of such CDSSs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Thus, it is necessary to gain knowledge of how they are used in various contexts and for various patient groups.\u003c/p\u003e \u003cp\u003eMusculoskeletal (MSK) disorders are the leading cause of years lived with disability worldwide and represent a considerable burden to the individual and society (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Clinical decision support tools for this patient group are rapidly expanding; however, inconsistent or preliminary findings with limited validity testing, effectiveness- and impact evaluation studies have been reported (\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The SupportPrim PT (physiotherapy) is a CDSS developed to provide biopsychosocial treatment suggestions for managing musculoskeletal pain disorders in primary care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The CDSS identifies similar successful patients and their treatment and aims to support the shared decision-making process of physiotherapists and patients. In physiotherapeutic care, shared decision-making can be defined as a process that \u0026ldquo;enables a clinician and patient to participate jointly in making a health decision, having discussed the options and their benefits and harms, and having considered the patient's values, preferences and circumstances\u0026rdquo; (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), p. 35. However, introducing CDSSs presents a paradigmatic shift from a dyadic relationship between the patient and the clinician into a triad, including the CDSS (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Whereas CDSSs have been found to align agendas and empower patients to present their preferences more efficiently (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), they may also introduce several challenges in patient‒clinician interactions. For example, they can lead to changes in responsibility and decision-making authority (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), and some healthcare workers fear that professional autonomy will be reduced (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA qualitative study exploring the development and acceptance of a preliminary version of the SupportPrim PT CDSS found that while it positively impacted the therapeutic relationship, patients were seldom included in treatment decisions (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). However, the study did not explore decision-making dynamics specifically, and the physiotherapists were not experienced in using the CDSS. Therefore, this study aims to explore how a CDSS providing personalised treatment support for MSK disorders influences the decision-making process of physiotherapists and patients.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis qualitative study is based on individual interviews with physiotherapists and patients within Norway's primary healthcare sector using the SupportPrim PT CDSS in a randomized controlled trial registered with ISRCTN (ISRCTN17927832). In Norway, patients have direct access to physiotherapy in primary health care. The first consultation usually lasts 30\u0026ndash;60 minutes, whereas the second consultation lasts between 20\u0026ndash;30 minutes, and treatment commonly consists of a combination of education, exercises and passive modalities. The SupportPrim PT CDSS (hereafter referred to as `the CDSS\u0026acute;) was developed to improve healthcare management of common MSK disorders in primary physiotherapy care (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Since these disorders are highly individual and influenced by a variety of biological, psychological, and social factors, the CDSS aims to account for patients' heterogeneity by providing personalised treatment. Using case-based reasoning (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), a problem-solving method in artificial intelligence, the CDSS identifies similar patients and their treatment, intending to help patients and physiotherapists decide on appropriate treatment through shared decision-making.\u003c/p\u003e \u003cp\u003eThe SupportPrim PT CDSS intervention was carried out as follows. The physiotherapists (hereafter referred to as `therapists\u0026acute;) received educational material and individual education on how to use it. Patients answered web-based questionnaires before attending their first consultation, and the answers were displayed on a patient profile screen (\u003cspan refid=\"Sec21\" class=\"InternalRef\"\u003eappendix 1\u003c/span\u003e). The therapists could access this profile before the first consultation. The CDSS was designed for patients and therapists to explore together, before defining treatments goals. The therapists also needed to perform an examination and enter a diagnosis for the CDSS to identify the three most similar previous patients with successful outcomes, defined by a composite score of biopsychosocial domains (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The patient and the three most similar patients were then displayed on a treatment decision screen (\u003cspan refid=\"Sec22\" class=\"InternalRef\"\u003eappendix 2\u003c/span\u003e), which also included personalised treatment recommendations based on factors associated with high symptom severity (such as low physical or social activity, sleeping disorders, mental distress, poor workability, fear avoidance, low pain self-efficacy and low expectations of recovery). Detailed descriptions of the development and content of the CDSS are published elsewhere (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResearch participants and recruitment\u003c/h3\u003e\n\u003cp\u003eThis study is based on a purposive sample of participants. Ten therapists and 11 patients who participated in the randomised controlled trial were recruited by email (therapists) or telephone (patients) by AFB or NEK for individual, semi-structured interviews conducted between April and June 2021. Therapists were primarily recruited based on their experience with using the CDSS, and we also aimed to include participants presenting a variety of sex, age, specialities, and clinical experience.\u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e HERE\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePhysiotherapist characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSpeciality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eClinical experience\u003c/p\u003e \u003cp\u003e(years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCDSS use\u003c/p\u003e \u003cp\u003e(no. of patients)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysiotherapist with education in manual therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysiotherapist with education in psychologically informed physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePhysiotherapist with education in manual therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGeneral physiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*M\u0026thinsp;=\u0026thinsp;male, F\u0026thinsp;=\u0026thinsp;female\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe patients were consecutively recruited based on the number of patients with whom their therapist had used the CDSS. We chose to include patients whose therapists had used it with at least six patients. The interviews were conducted within two months of the first consultation.\u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e HERE\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSex*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMain problem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003cp\u003eof painsites\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePain duration\u003c/p\u003e \u003cp\u003e(months)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultisite/complex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShoulder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultisite/complex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultisite/complex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u0026ndash;3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*F\u0026thinsp;=\u0026thinsp;female, M\u0026thinsp;=\u0026thinsp;male\u003c/p\u003e \u003cp\u003e The interview guide for the therapists included questions regarding their approach when using the CDSS, what they found valuable and challenging, what changes they had to make to ordinary practice, who they believed would benefit from using the CDSS and their perceptions of how patients experienced using it. The interviews increasingly focused on exploring the therapists' reasoning on how they used the CDSS with specific patients and chose not to use it with others. The interview guide for the patients included questions regarding their experiences with using the CDSS, for example, if the patient profile reflected their understanding of their health and how they felt about the therapists having access to it before the first consultation, the relevance of using similar patients to decide on treatment, what they found valuable and how the CDSS could be changed to better suit their needs. The interviews increasingly focused on exploring whether patients felt involved by their physiotherapists and how they interacted in using the various parts of the CDSS, especially when deciding on treatment.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e The participants were asked if they wanted to be interviewed by telephone or in a digital meeting since they resided in various parts of the country. All interviews lasted approximately 30\u0026ndash;60 minutes, and the audio was recorded and transcribed verbatim. Either NEK or NEK and AB together performed the interviews, both of whom had previous experience conducting interviews.\u003c/p\u003e\n\u003ch3\u003eTheoretical approach\u003c/h3\u003e\n\u003cp\u003eActor Network Theory (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) has inspired both the analysis and the discussion of the results. Viewing the social and technological dimensions as intimately entwined, the theory has been described as useful for exploring how technology shapes social processes (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Actor Network Theory focuses on the interplay between technology and its users, seeing nonhuman elements as actors that can enable and mediate action by interacting with other actors. The reciprocal relationship between the technological and the social is further described by the term \u003cem\u003edelegation\u003c/em\u003e (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), while we delegate work to technologies, technologies also delegate behaviour back into the social, influencing and shaping actions within sociotechnological networks. As such, the theory is not concerned with merely mapping interactions; it includes the process of \u003cem\u003etranslation\u003c/em\u003e (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) in which the actors define roles and delimit and negotiate the possibility of interaction and their margins of manoeuvre (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). In this study, Actor Network Theory is used as a framework to explore how patients and therapists interact with each other and with the CDSS and how these interactions influence the decision-making process.\u003c/p\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003eThe interviews were analysed thematically (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), inspired by the Actor Network Theory perspectives on interaction (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). One researcher with a social science/public health research background (NEK) and three with physiotherapy and public health research backgrounds (FG, AB, IM) contributed to the analysis. NEK read all the interviews, noting initial thoughts on their content before coding them individually. FG and AB read and coded two interviews to compare interpretations. The interviews were coded inductively, paying particular attention to how the CDSS influenced experiences and interactions during the decision-making process. In line with the theoretical approach, we also attempted to identify occasions where the participants described how the CDSS influenced their thoughts, feelings, or actions through the following question: `What does the CDSS \u003cem\u003edo\u003c/em\u003e and \u003cem\u003ehow\u003c/em\u003e?\u0026acute;. As such, the themes are analytic abstractions of the participants' descriptions of how they experienced using the CDSS and what they believed it contributed to. NEK, FG and AB discussed the coding and preliminary themes before the first draft of the results. This draft was discussed with the remaining author IM, and in the further analytic process, the themes were adjusted into a chronological narrative based on how the CDSS was used.\u003c/p\u003e \u003cp\u003ePLEASE INSERT Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e HERE\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCoding tree\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain themes, sub themes and quotes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 Visualising health status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Expanding and aligning perceptions of health issues - \u0026ldquo;We will perhaps talk about more than \u003cem\u003ejust\u003c/em\u003e the painful knee\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Providing latitude to address health issues - \u0026ldquo;I find it a lot easier to point things out\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Creating insecurity of prognosis - \u0026ldquo;It is perhaps almost a bit intimidating for those with many and complex issues\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 Confirming treatment decisions\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Supporting clinical reasoning - \u0026ldquo;I feel that I get confirmation on doing a lot that others are doing too\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Lending authority to therapists - \u0026ldquo;`That\u0026acute;s exactly what we agreed upon last time, then we know we are on the right track\u0026acute;\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e◦ Demanding active management - \u0026ldquo;What factors does the system use to find these similar patients?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eQuotes were selected to provide an interpretational context and exemplify or nuance the analytic text.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The Regional Committee for Medical and Health Research Ethics in Norway approved the study (49308/2020), and all patients provided written informed consent before participating. The study was performed in accordance with the Declaration of Helsinki. Since the therapists and patients were not matched, the interviews with the therapists did not reveal the health information of identified patients.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eFrom the interviews, we found that patients and therapists highly valued the visualisation of the patient's health status and that the therapists appreciated how the CDSS predominantly confirmed their treatment decisions. However, the CDSS also presented some challenges, and the patient interviews revealed that only two patients had used the treatment decision screen with the therapist, and six had not seen any screens. The following results expand on these findings.\u003c/p\u003e\n\u003ch3\u003e1 Visualising health status\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eExpanding and aligning perceptions of health issues\u003c/b\u003e\u003c/h2\u003e \u003cp\u003ePatients and therapists described the CDSS as enabling them to expand and align their views on relevant information about the patient's health issues and further treatment. Several patients believed that they would have revealed less information without the CDSS, either because they were unaware of the information\u0026rsquo;s relevance, would forget something, or because of their personality type:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eOtherwise, I don\u0026acute;t talk much about my life; I\u0026acute;m not the type that says much, no matter how painful things are. I don\u0026acute;t express it. (\u0026hellip;) Therefore, the questions regarding sleep and such things were very accurate in my case because I struggle to sleep. (Patient 7)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe therapists found that patients were primed into a psychosocial view of health and seemed more prepared by the first consultation due to answering the questionnaires. Some described this as improving the consultation flow and facilitating their work as a therapist:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe patients are somewhat more prepared for what will happen\u0026mdash;that we will perhaps talk about more than \u003cem\u003ejust\u003c/em\u003e the painful knee when they enter the door. And they have thought about the bigger picture and how it affects their life before they arrive. (Therapist 9)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough several therapists said that they retrieved similar information as displayed in the patient profile of the CDSS in their regular practice, most used several consultations to do so. Some therapists also said that the CDSS revealed information on topics they did not address in their regular anamnesis, either because of busy workdays or because attending to such topics felt unnatural. For example, one therapist had become attentive to how she often refrained from addressing psychosocial issues with some men and that the CDSS provided surprising information: \u0026ldquo;I am somewhat disappointed in how little I perhaps\u0026hellip; Well, I believe patients communicate easily with me, and now I understand that if it wasn\u0026acute;t for this [CDSS], there are things I probably would have missed\u0026rdquo; (Therapist 8). As such, the CDSS revealed information that also reminded therapists to pay increased attention to psychosocial health aspects.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eProviding latitude to address health issues\u003c/h2\u003e \u003cp\u003eBoth therapists and patients highly valued how the CDSS provided a thorough first impression of the patient's health status that helped address relevant issues. The patients predominantly felt that the patient profile reflected their health experience and gave therapists an improved impression of their situation. One patient described the visualisation in the CDSS as an objective representation of her health: \u0026ldquo;I liked it, truly - to have more perspective on it [my health situation], and it\u0026rsquo;s a good thing that others see it as well; it becomes a bit less subjective. It becomes like this: `Ok, here I can see that you have this and that\u0026acute;\u0026rdquo; (Patient 1). Some therapists also described how the CDSS provided a more authentic or accurate representation of health that facilitated their approach to patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIt is much easier to talk about a problem when you have the patient more or less statistically unfolded on the screen before you. I find it a lot easier to point things out because what is nice about that screen is that it says, for instance, if psychosocial challenges are showing red, it is much easier to talk to the patient about it and address the various themes. After all, the patients said it themselves, only in advance. (Therapist 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs such, the CDSS was found valuable in granting therapists latitude to address aspects relevant to the patient's treatment. Viewing the screen together was described by several therapists as a valuable means to facilitate `the good conversation\u0026acute; as it was disarming to patients compared with potentially uncomfortable or confrontative eye contact in regular consultations.\u003c/p\u003e \u003cp\u003eThe comprehensive information revealed by the CDSS also entailed that some therapists felt obliged to address the issues patients had reported. Although they predominantly seemed to find it useful, patients sometimes appeared surprised to have issues other than their main concern addressed:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eLast week, I had someone with \u003cem\u003epoor\u003c/em\u003e mental health. But she was here because of a knee, so when I addressed it and said: `I can see this [in the CDSS]\u0026acute;, tears were running, and there was a conversation about it and a note to the general practitioner about it. Then, we continued to work on what we do. So that is one type of thing... I believe they answer the questions honestly, perhaps not thinking we will see it because some have seemed surprised that I have it [the information] once they arrive. (Therapist 8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCreating insecurity\u003c/h2\u003e \u003cp\u003eAlthough the interviews showed that patients commonly underlined the importance of addressing relevant health issues, it proved problematic for some. Not all felt comfortable completing the questionnaire or facing the therapist after providing sensitive information. One patient described the questionnaire as challenging since he expected questions regarding his mental health to appear; this was a sensitive topic, as he was feeling increasingly depressed owing to loss of function:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ePatient: I was a bit worried that I would be asked the question: `Do you want to commit suicide?\u0026acute; Truly. Yes, it was a bit like: `When will the question come when they ask if I am in danger of committing suicide?\u0026acute; (\u0026hellip;)\u003c/p\u003e\u003cp\u003eInterviewer: To enter her [the therapist\u0026rsquo;s] office when she had this information about you in advance, how did you experience that?\u003c/p\u003e\u003cp\u003ePatient: Heh, it was intimidating. It was. And that was because of all those questions.\u003c/p\u003e\u003cp\u003e(Patient 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn this case, the patient described the therapist dealing explicitly with psychological issues before commencing physical treatment, something he found valuable despite his initial response to the questionnaire. Several therapists also believed that the visualisation of health information and prognosis potentially was disheartening for some patients, especially those with many complex and severe health issues. Therefore, most therapists underlined the necessity of viewing the patient profile before the first consultation, proceed with caution, and downplay the information to avoid alarming patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI have experienced that it is perhaps almost a bit intimidating for those with many and complex issues. Especially this first picture where every arrow is red, it can be a bit\u0026hellip; Well, I have been unsure to what extent I want to view it [with the patient] simply because it lights up red in every corner and looks dismal. (Therapist 8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne therapist also noted that being made aware of the high severity of symptoms before meeting the patient could negatively influence the therapists' assessments.\u003c/p\u003e \u003cp\u003eWhile most patients underlined their awareness of their health issues beforehand, some described becoming increasingly attentive to their relevance or scope after having them visualised:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI started to reflect more about my sleep because it\u0026hellip; I do not believe I reflected upon answering that it was poor, but this system picked up moderate or medium sleep problems. So that was more evident to me; it was nice really. (\u0026hellip;) I know that I sleep poorly sometimes, but when you see it crystal clear that you have sleep problems, then I find that it is perhaps something I should address or do more about. (Patient 1)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn this case, the therapist merely mentioned the topic without addressing it further, which was something the patient did not react to since it was not the therapist\u0026rsquo;s area of expertise. However, one therapist also noted that comprehensive mapping and visualisation of health issues could lead to overtreatment of patients, who, on their part, are satisfied with merely a few tips to resolve a specific health issue. Having to attend to sensitive information they felt unable to manage themselves was also described as challenging by some therapists. In particular, those practising in areas with high pressure on health services, in rural areas with few referral opportunities, or with patients betwixt and between specialists found it troublesome, as they felt left with attending to the patient's issues themselves:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe challenge is, to whom can I refer? These kinds of patients fall between all chairs\u0026mdash;not severe enough to enter the community-based mental healthcare centres and not serious or specific enough for any special department. (Therapist 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Most therapists and patients still underlined that, although it could initially create insecurity, providing relevant information was beneficial, as it provided an opportunity to address key factors in treatment. When asked what they believed revealing such comprehensive information contributed to, one therapist replied: \u0026ldquo;probably to a better comprehension of the fuller picture, of the life situation, how the pain and function problematics affect the life situation, and it probably also enables me to use the right treatment tools\u0026rdquo; (Therapist 7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2 Confirming treatment decisions\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eSupporting therapist reasoning\u003c/h2\u003e \u003cp\u003eWhen explaining what they believed a \u003cem\u003edecision support system\u003c/em\u003e entailed in this setting, the therapists commonly underlined that the role of the CDSS was to support them in deciding on appropriate treatment. Although a few therapists described utilising some treatment suggestions from the CDSS in addition to their own, most said it supported already planned treatment. For some, this was particularly valuable due to the context of their practice:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI use it as a support, a backing actor in a way. And to me, who is without colleagues, situated alone in the outback, it is worth its weight in gold (laughing). (\u0026hellip;) I feel that I get confirmation on doing a lot that others are doing too, and you might get some useful suggestions as well, things you might pick up on. (Therapist 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAlthough involving patients was commonly described as an essential means to provide more ownership of the treatment process later on, the therapists usually referred to patients as `more active than usual\u0026acute; in relation to the patient profile, i.e., in providing information and discussing their situation. Few referred to the CDSS as enabling a process of shared decision-making regarding treatment, and some therapists described that not all patients should be included if the therapist felt secure in their treatment choice. The interviews with the patients mirrored the therapists' description in that most felt very much included in the consultations and valued being active while happily leaving the task of deciding on treatment to the therapist, trusting that s/he knew best: \u0026ldquo;I was like: `Just give me exercises I can do or give me a plan, and I will follow it\u0026acute;. I was very open since I had no understanding of why I was in pain. (...) I do not have the knowledge about that, and then I trust those who know more\u0026rdquo; (Patient 1). However, some therapists also underlined the need to ensure that the discrepancy between the patient's wishes and what they considered appropriate treatment was not too large to maintain trust in the relationship. Therefore, some would occasionally provide treatment that they found unnecessary.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLending authority to therapists\u003c/h2\u003e \u003cp\u003eIn addition to providing therapists with confidence in their reasoning, several therapists also spoke of actively using information from the CDSS's treatment decision screen as a pedagogic tool. They would then show the patients the screen if it confirmed their treatment plans:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen you look at similar patients, we look together at what treatment the patients found useful, and then you can: \u0026acute;Well, that\u0026acute;s exactly what we agreed upon last time, then we know we are on the right track\u0026acute;. It is somewhat of a confirmation tool almost (laughs), you know, it is very useful in the instances when [the patient] needs some motivation\u0026mdash;to be able to pull it [the CDSS] out in the second run to confirm that what I had figured out, it turned out to be very good! (Laughs). (Therapist 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome also described that the CDSS enabled them to build trust and reason with or persuade patients about the treatment choice. In line with the patient's descriptions of the CDSS as a more objective representation of their health, several therapists found it useful since it helped in determining or confirming what is `true\u0026acute;: \u0026ldquo;a nice thing about this system is that you get a clarification of what is true, right, it isn\u0026acute;t just me, I have backing on what I am saying. I believe that is important\u0026rdquo; (Therapist 6). As such, the CDSS can be said to lend the therapist authority\u0026mdash;if their suggested treatment aligned with the CDSS. In addition, several therapists spoke of reviewing the graphs that explained progression over time as an aid in normalising pain and building motivation owing to the clear visualisation of progress:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think it is easier to get patients who are not that motivated to work out and do physical exercises and all that to budge some more when you have these visible graphs and pictures to showcase; it is somewhat easier to motivate them and: `Look at this!\u0026acute; (\u0026hellip;) Then, they can see that the pain graph usually increases some in the beginning and then declines. (Therapist 4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe trajectories were often used in the following consultations to reassure patients, for instance, if they did not experience pain reduction after starting treatment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDemanding active management\u003c/h2\u003e \u003cp\u003eAlthough the therapists described the treatment suggestions mainly as valuable confirmations, they occasionally found them inappropriate and deviating from their clinical reasoning. In addition, the information in the treatment decision screen was considered abundant and often too complex for patients. Therefore, therapists had to manage this part actively - if they chose to show it to patients.\u003c/p\u003e \u003cp\u003eIf the therapists found that the patients identified as similar by the CDSS were inappropriate, they sometimes questioned the CDSS\u0026rsquo;s algorithms: \u0026ldquo;What factors does the system use to find these similar patients? What are they comparing? Sometimes it is very evident, other times I am thinking: `these patients are just entered randomly and doesn\u0026acute;t fit at all\u0026acute;\u0026rdquo; (Therapist 9). Most therapists explained their low level of trust in the CDSS\u0026rsquo;s suggestion of similar patients because of the low number of patients included in the patient pool, and when encountering dissimilar suggestions, most told of not showing them to the patients. In other cases, seemingly similar patients had unsuitable treatment suggestions. For example, one therapist noted how suggestions for patients diagnosed with chronic fatigue syndrome were sometimes contraindicated owing to the amount of activity suggested. Some therapists also experienced that the CDSS suggested treatment supporting patients' biomechanical view of health or wish for passive treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I have finished the patient profile, finished the examination and set a goal and that part [of the CDSS], I already have a fairly clear idea of where I want to go next. (\u0026hellip;) We have perhaps started talking about a plan, using more active management strategies, exercises and have a comprehension of how to handle the pain. And \u003cem\u003ethen\u003c/em\u003e, when we open the part with similar patients, and it describes that it is very useful to receive stretching and passive treatment (laughs). When I see that, I do not want to open that door when we have already started moving in another direction. (Therapist 2)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis quote also exemplifies how many therapists found the patient profile sufficient to set a treatment course after the first consultation, and as such, the treatment decision screen could prove disruptive to practice flow if suggestions diverged. Most therapists told of waiting to use this screen until the second consultation because of the additional time used to review the patient profile, insecurity in similar patients\u0026rsquo; treatment suggestions, and the overall complexity of this part of the CDSS. In contrast to the simplicity of the patient profile, the treatment decision screen was experienced as more challenging to use due to the need for thorough explanations. Although most therapists felt knowledgeable in using the CDSS after 3\u0026ndash;4 patients, some experienced that they still did not know how to utilise this part of the CDSS optimally after ten or more patients and that it sometimes was best to refrain from showing it to the patients altogether to avoid insecurity.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis is the first study to explore therapists\u0026rsquo; and patients\u0026rsquo; experiences with using a CDSS based on case-based reasoning that provides personalised treatment suggestions for MSK disorders. We found that patients and therapists valued the visualisation of health status, as it gave them latitude to address relevant health aspects and align views, although it occasionally created some insecurity. The therapists felt supported by the CDSS since the treatment decision screen predominantly reflected their clinical reasoning, and they sometimes used it to lend authority towards patients. However, the CDSS also contained complex information and, occasionally, inappropriate treatment suggestions, leading therapists to examine it in advance and carefully select which information to share with patients. The lack of patient involvement was also reflected in the patient interviews, revealing that very few had seen the treatment decision screen.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eThe dynamics of the decision-making process\u003c/h2\u003e \u003cp\u003eWhereas previous studies have found that CDSSs can facilitate shared decision-making (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), the present study shed light on how and why therapists may also adjust patient involvement relative to the perceived appropriateness of CDSS information. The findings largely align with previous research on the SupportPrim PT CDSS, where patients and therapists were found to value it as a preparatory and exploratory tool positively impacting the therapeutic relationship, whereas treatment suggestions mainly supported ordinary practice instead of involving patients (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Whereas the lack of user experience could explain the low involvement of patients in the former study, the present study reveals that therapists who are more experienced with the CDSS often chose not to do so as well. Inspired by the Actor Network Theory concept of \u003cem\u003etranslation\u003c/em\u003e, a process \"during which the identity of actors, the possibility of interaction and the margins of manoeuvre are negotiated and delimited\" (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), p. 201, the following discussion explores how the three main actors (the CDSS, therapists, and patients) influence and delimit the actions of one another at different time points of the decision-making process. We elaborate on these dynamics according to the two main parts of the CDSS: 1) the patient profile in which the patient's health problem is defined and 2) the treatment decision screen where treatment is suggested.\u003c/p\u003e \u003cp\u003e1) Defining the problem\u003c/p\u003e \u003cp\u003eThe results suggest that the CDSS plays an important role in shaping the views of the patient's health problem, severity, and prognosis. The CDSS can be said to \u003cem\u003edelegate\u003c/em\u003e (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) the behaviour of the other actors by determining topics in the questionnaire, transforming the answers through inherent cut-offs to be visualised in the patient profile, and further determining what to address. A main finding is that thorough patient mapping and shared viewing of the patient profile increases trust - both the patients' trust in the therapists and the therapists' trust in their own reasoning. Decision-making has previously been described as including the role of patient illness narratives and subjective symptoms in relation to the CDSS's information (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In a study by Barken et al. (2017), nurses frequently overrode system decisions since the CDSS was found inadequate to structure or provide sufficient clinical information, whereas the therapists in the present study found that the CDSS\u0026acute;s thorough patient information reflected patients and exceeded their regular anamnesis. Feeling more confident at an early point in the treatment process, several described the patient profile as sufficient to decide on treatment, thus underlining that the CDSS can have contributed to changes in practice, even if the subsequent comparison with similar patients did not produce novel insights.\u003c/p\u003e \u003cp\u003eAlthough the patients and therapists appreciated how the visualisation of patients' health status in the patient profile provided a comprehensive view to decide on appropriate treatment, some expressed concerns regarding its scope, as it occasionally included more information than expected. It has previously been pointed out that employing CDSSs with vast technological options might deviate from dealing with the patient's concerns by conveying secondary findings (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). In the present study, patients seeking specific advice for a recent knee injury could, for example, find themselves discussing mental health issues in their first consultation. The ethical aspects of having physicians deal with issues outside the scope of their competency when using CDSSs have previously been linked to medicalisation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Reflecting this perspective, some therapists believed patients could become aware of and worry about health issues they would otherwise handle well, and that addressing psychosocial problems could be challenging for therapists, potentially leading to overtreatment. In addition, some expressed concern about the limited access to psychologists and physiotherapists with education in psychologically informed physiotherapy. A previous study on Norwegian physiotherapists found that although they had a multidimensional perspective on low back pain, they also believed that integrating psychosocial domains depends on clinical experience and that some demands may lie outside their professional competence (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Given the authority ascribed to the CDSS by patients and therapists in the present study, i.e., referring to the information as more `objective\u0026acute; or `true\u0026acute;, education on addressing and managing the potentially sensitive information the CDSS reveals is essential and should be done with caution.\u003c/p\u003e \u003cp\u003e2) Deciding treatment\u003c/p\u003e \u003cp\u003eAlthough the patient profile seems to increase trust and patient involvement, this appears to negatively impact the intended use of the treatment decision screen, as few patients have seen it. We identified several aspects that influence the dynamics of the decision-making process and may explain why treatment was not decided as intended.\u003c/p\u003e \u003cp\u003eFirst, patients\u0026rsquo; and therapists\u0026rsquo; \u003cem\u003eexpectations of the CDSS and each other's roles\u003c/em\u003e seem to influence use dynamics. Most therapists interpreted `decision support\u0026acute; as the CDSS's role in supporting their own decision-making process with various degrees of patient involvement, suggesting that the terminology proves misleading and/or that education on the intentional use of the CDSS is insufficient. Describing involvement as `high\u0026acute; can further reflect the relativity of `being involved in decision-making\u0026acute;, as most patients were involved more than expected in discussing their health issues. This finding also suggests that defining a patient's health issue is perceived as an essential part of the decision-making process. The trust in therapists as best suited to decide treatment and patients neither expecting nor wanting further involvement depends on the trust cultivated from reviewing the information in the patient profile and the alignment between the therapists' and the CDSS's treatment suggestions. A previous study has underlined that while patients may expect improved care from CDSSs, they simultaneously want to keep clinicians in the decision-making loop due to their clinical experience and ability to evaluate the CDSS outputs (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). While shared decision-making entails the patient's right to participate to the extent that they want when decisions regarding their healthcare are made (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), future studies should ensure that all participants receive sufficient information and education on the intention and potential use of the CDSS.\u003c/p\u003e \u003cp\u003eThe CDSS generated treatment suggestions based on similar patients intending to have the therapist and patient discuss its relevance further and did not explicitly include the patient's values and preferences. This could lead to `computer paternalism\u0026acute; (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) (or `CDSS-paternalism\u0026acute;), undermining the patient's autonomy and authority over their treatment if the therapist chooses not to integrate these aspects in decision-making. While patients\u0026rsquo; values, preferences and circumstances are important components of shared decision-making (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), dynamic variables such as human behaviours and environmental factors are seldom incorporated into CDSS algorithms (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Therefore, therapists need to consider the broader context of the patient\u0026ndash;therapist\u0026ndash;CDSS encounter when delimiting what constitutes appropriate treatment when applying a CDSS in this setting. It should also be noted that patients attending physiotherapy for low back pain in Norway initially expect exercises and a body-oriented diagnosis, whereas their view of pain and management shifts towards a more biopsychosocial perspective after being in treatment (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The current study suggests that a CDSS with a biopsychosocial orientation might help therapists facilitate this change in perspective earlier, which may also have positive implications for treatment adherence.\u003c/p\u003e \u003cp\u003eSecond, the \u003cem\u003etiming and content of treatment suggestions\u003c/em\u003e appear to reduce the relevance of the CDSS for deciding treatment. Many therapists found the information from the patient profile sufficient to start treatment. While the treatment decision screen also proved too time-consuming to include in the first consultation, reviewing it in the second disrupted the natural progression of the decision-making process for some. This is an important challenge since CDSSs that provide decision support at the time and location of decision-making succeed better than others (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In addition, treatment recommendations mostly confirmed the therapists' reasoning, suggesting that the CDSS's content and algorithms aligned with already established practices, i.e., presenting a logic of continuation rather than disruption or change (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), which was the system's intention. As such, the present CDSS's treatment suggestions seem to contain information of limited use, leading therapists to cherry-pick already familiar treatments instead of being provided novel plug-and-play suggestions to test. Previous studies have emphasised how innovations positively impacting clinical routines by making sense or adding meaning are more likely to succeed (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Taken together, this CDSS\u0026rsquo;s relevance in deciding treatment based on similar patients and personalised treatment recommendations is not evident.\u003c/p\u003e \u003cp\u003eThird, yet perhaps most important, patient involvement in shared decision-making is hindered by the \u003cem\u003etherapist\u0026rsquo;s ability and need to interpose\u003c/em\u003e between the CDSS and the patient. While the CDSS has the potential to question the therapist\u0026rsquo;s reasoning when viewed together with the patient, this is inhibited by the therapist being an \u003cem\u003eobligatory passage point\u003c/em\u003e (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). As such, they may either distance patients by rejecting the CDSS\u0026acute;s relevancy or transform components of the CDSS into active support by bringing them into the decision-making process as validation of their clinical reasoning, i.e., having the CDSS lend them authority. Whereas this may result in valuable trust in the therapist and present a means to build patient motivation, it simultaneously appears to be a mechanism reducing patients' agency by not granting them full access. The absence of transparency in system architecture and output explainability can lead to challenges in evaluating the significance, quality, and implications of the CDSS outputs, and since clinicians' understanding of such systems exceeds that of patients', it has implications for \"the ability to exercise well-informed agency in the context of shared clinical decision-making\" (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), p. 4. This asymmetric agency caused by differences in competence and access enables the therapists in the present study to use the CDSS as a source of authority, ensuring that their treatment suggestions appear valid. Liberati and colleagues (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) identified clinicians' fear of losing control over autonomous decision-making and having their clinical autonomy reduced by providing nonmedical expert authority to judge medical decisions as the most severe barrier to CDSS uptake. Others have also noted how CDSSs can influence expectations, verdicts, roles, and responsibilities, thus altering clinicians' decisional authority (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In the present study, some of these concerns might have led therapists to avoid using treatment suggestions from similar patients in the intended way. However, the abundant and complex information in the CDSS also causes interpretative flexibility, \u003cem\u003erequiring\u003c/em\u003e therapists to act as interposers. As such, a reason for not using the CDSS could also be that therapists are experienced in using the system, finding it redundant for those with acute and specific conditions and presenting unnecessary insecurity if the patient\u0026acute;s situation is severe or inappropriate treatment is suggested. The value of individual data sovereignty, where patients are provided the right to exercise informational self-determination by co-managing their data, has previously been highlighted regarding CDSSs (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Whereas such access could enhance shared decision-making in the present study, it will also leave therapists unable to screen inappropriate information, emphasising the need to ensure its quality and relevance. The excessive and occasionally inappropriate information thought by therapists to cause insecurity in the present study should be addressed, as it significantly influences the intended use of the CDSS. Since the introduction of CDSSs creates new conditions for the roles of and interaction between patients and therapists in the decision-making process, therapists should also be guided on how to handle the challenges and utilise the benefits such systems present in clinical encounters.\u003c/p\u003e \u003cp\u003eStrengths and limitations\u003c/p\u003e \u003cp\u003eThis study contributes valuable information on the mechanisms of using a CDSS, i.e., how various aspects of a system might be experienced as valuable by users while still undermining its intention. The authors represent various backgrounds, and the study results have been presented and discussed in research groups consisting of participants with knowledge of both the topic, patient group and methodology. Whereas authors IM, FG and AB developed and implemented the system, the first author, NEK, contributed to the system's evaluation process. Physiotherapists with various specialties participated in the study. While the findings suggest some variation between the experiences of the physiotherapist with education in psychologically informed physiotherapy and the others, we chose not to investigate this further because of only one recruited therapist with such education. The patients' interviews did not provide sufficient knowledge to investigate their experiences with the treatment decision screen in detail, and the results lean heavily on the therapists\u0026rsquo; experiences with this part of the CDSS. However, the low number of patients familiar with this part of the CDSS also represents a key finding of the study, and the therapist interviews provided valuable insights into their reasoning for not including patients when using it. Notably, the lack of active use on the part of the patients does not necessarily mean that the CDSS was not used in the consultations since the therapists nevertheless found it useful when deciding on treatment. The majority of the interviews were conducted by telephone, possibly omitting important nonverbal information. Focus group discussions with therapists could also have yielded further information on their perceptions and reasoning for system use, and observational studies could have provided valuable information on the interaction between the actors and how the therapists differentiated their use according to specific patient characteristics. Future studies would benefit from such methodological triangulation.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe results of this study provide insight into the dynamics of the decision-making process between physiotherapists and patients when using a CDSS to decide on treatment for MSK disorders. Expanding and aligning views on patients\u0026rsquo; health issues may cultivate trust in the therapist's clinical reasoning, and a CDSS can prove valuable in deciding on appropriate treatment early in the treatment process. However, this trust may simultaneously challenge shared decision-making. Other aspects that may influence the dynamics of the decision-making process include expectations of the CDSS and the other actors\u0026acute; roles, as well as the timing and content of the CDSS. Furthermore, therapists' ability and need to interpose between patients and the CDSS can reduce patients' agency, and a lack of joint access allows the CDSS to be used to lend therapists authority instead of enabling shared decision-making. Future studies should investigate how CDSSs can enhance patient agency by providing access and how physiotherapists' role changes once tools influencing patient interaction and decision-making are introduced to clinical encounters.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCDSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eclinical decision support system\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMSK\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emusculoskeletal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ephysiotherapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Regional Committee for Medical and Health Research Ethics in Norway (49308/2020), and all patients provided written informed consent before\u0026nbsp;participation. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent\u0026nbsp;for publication can be made available upon request from the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available since the study\u0026nbsp;participants’\u0026nbsp;consent did not include such permission. However, they are available from the corresponding author\u0026nbsp;upon\u0026nbsp;reasonable request and with\u0026nbsp;the\u0026nbsp;permission of the study participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe project was funded by the Norwegian Research Council (ref. nr: 303331).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNEK designed the study;\u0026nbsp;collected, analysed and interpreted\u0026nbsp;the\u0026nbsp;data;\u0026nbsp;and wrote and completed the manuscript. FG designed the study, contributed\u0026nbsp;to the analysis and interpretation of\u0026nbsp;the data, and was a major contributor to\u0026nbsp;the\u0026nbsp;writing and\u0026nbsp;completion of\u0026nbsp;the manuscript. AB designed the study, collected\u0026nbsp;the\u0026nbsp;data,\u0026nbsp;contributed\u0026nbsp;to the analysis and interpretation of\u0026nbsp;the data, and in\u0026nbsp;writing\u0026nbsp;the manuscript. IM designed the study and contributed\u0026nbsp;to the interpretation of\u0026nbsp;the data and writing\u0026nbsp;of\u0026nbsp;the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to thank all\u0026nbsp;the\u0026nbsp;participants for contributing their time and experiences with using the SupportPrim PT CDSS. We also wish to express our deepest gratitude to Professor Ottar Vasseljen, who passed away on January 19\u003csup\u003eth\u003c/sup\u003e 2024, for his significant contributions, including the conception of the various SupportPrim CDSSs, for leading the project group in developing the CDSSs and for his involvement in the present study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSutton RT, Pincock D, Baumgart DC, Sadowski DC, Fedorak RN, Kroeker KI. An overview of clinical decision support systems: benefits, risks, and strategies for success. NPJ Digit Med. 2020;3:17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaynes RB, Wilczynski NL. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: methods of a decision-maker-researcher partnership systematic review. 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J Health Organ Manag. 2014;28(1):96\u0026ndash;114.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"case-based reasoning, data sovereignty, clinical reasoning, clinical autonomy","lastPublishedDoi":"10.21203/rs.3.rs-5181191/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5181191/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClinical 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study is nested within a randomised controlled trial and is based on individual interviews with 11 patients with musculoskeletal disorders and 10 physiotherapists in Norwegian primary healthcare in 2021. The interviews were analysed thematically, with a theoretical approach inspired by Actor Network Theory.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFirst, both patients and physiotherapists valued the visualisation of patients\u0026rsquo; biopsychosocial health status. It helped address health issues and expand and align perceptions of relevant information, leading to trust in physiotherapists\u0026rsquo; 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\u0026rsquo; trust in the CDSS.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCDSSs can prove valuable by cultivating trust in physiotherapists\u0026rsquo; 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.\u003c/p\u003e","manuscriptTitle":"Decision support in the management of musculoskeletal disorders: a qualitative study of physiotherapists’ and patients’ experiences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 10:45:28","doi":"10.21203/rs.3.rs-5181191/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-07T15:34:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-06T02:50:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-06T02:49:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-09-30T13:20:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ab7a1165-1968-4271-827b-701f797a6c98","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-20T07:24:18+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-19 10:45:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5181191","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5181191","identity":"rs-5181191","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}