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Abstract Background Evolution of metabolism occurs through the acquisition and loss of genes whose products acts as enzymes in metabolic reactions, and from a presumably simple primordial metabolism the organisms living today have evolved complex and highly variable metabolisms. We have studied this phenomenon by comparing the metabolic networks of 134 bacterial species with known phylogenetic relationships, and by studying a neutral model of metabolic network evolution. Results We consider the 'union-network' of 134 bacterial metabolisms, and also the union of two smaller subsets of closely related species. Each reaction-node is tagged with the number of organisms it belongs to, which we denote organism degree (OD), a key concept in our study. Network analysis shows that common reactions are found at the centre of the network and that the average OD decreases as we move to the periphery. Nodes of the same OD are also more likely to be connected to each other compared to a random OD relabelling based on their occurrence in the real data. This trend persists up to a distance of around five reactions. A simple growth model of metabolic networks is used to investigate the biochemical constraints put on metabolic-network evolution. Despite this seemingly drastic simplification, a 'union-network' of a collection of unrelated model networks, free of any selective pressure, still exhibit similar structural features as their bacterial counterpart. Conclusions The OD distribution quantifies topological properties of the evolutionary history of bacterial metabolic networks, and lends additional support to the importance of horizontal gene transfer during bacterial metabolic evolution where new reactions are attached at the periphery of the network. The neutral model of metabolic network growth can reproduce the main features of real networks, but we observe that the real networks contain a smaller common core, while they are more similar at the periphery of the network. This suggests that natural selection and biochemical correlations can act both to diversify and to narrow down metabolic evolution.

Purpose: The rehabilitation model "Prevention of sickness absence through early identification and rehabilitation of at-risk patients with musculoskeletal disorders" (PREVSAM) was tested in a randomised controlled trial. This study aimed to explore participating healthcare professionals' experiences of working according to the PREVSAM model, and their perceptions of its clinical benefit and feasibility in primary care rehabilitation., Methods: A focus group study including 12 healthcare professionals from five primary care rehabilitation clinics was analysed according to the focus group methodology described by Krueger and Casey., Results: Four themes were identified. A clear framework describes how PREVSAM facilitates person-centred teamwork. The value of teamwork highlights benefits and challenges with teamwork. Through thick and thin discusses perceived patient benefits. In the ideal world focusses on feasibility of implementing the model., Conclusions: The participants experienced that the PREVSAM model may be beneficial for the patients, for their own work situation and workplace, and for society. Identifying psychological risk factors was perceived as helpful, but not enough to capture patients in need of team-based rehabilitation. While considered feasible, barriers for implementing the model were identified. Managers and healthcare policy makers must prioritise and create appropriate conditions for team-based musculoskeletal rehabilitation in primary care.

Introduction: To understand, diagnose and treat patients with musculoskeletal disorders, psychological risk factors should be assessed, and the association between psychological risk for disability and appropriateness of orthopedic surgery should be investigated., Purpose: To investigate the association between screened psychological risk for disability and appropriateness of orthopedic surgery, and to examine a physiotherapist's ability to assess risk for disability in patients referred for orthopedic consultation., Method: Patients ( n  = 192) were assessed by a physiotherapist or an orthopedic surgeon to determine the need for surgery. The Pain Belief Screening Instrument (PBSI) was used to screen for psychological risk. The physiotherapist assessed psychological risk for disability based on yellow flags. Association between PBSI risk profile and appropriateness of orthopedic surgery was analyzed using logistic regression. Sensitivity and specificity of the physiotherapist's assessment of risk was calculated using a binary classification model., Results: Orthopedic surgery was 2.28 times more likely to be considered an appropriate intervention for patients with a high PBSI risk profile (95% CI 1.09;4.78). The physiotherapist's risk assessment correctly identified 88% of those at low risk (specificity) and 32% of those at high risk for disability (sensitivity)., Conclusion: The findings suggest that orthopedic surgery is likely to be considered appropriate for patients with a high PBSI risk profile. The high specificity of the physiotherapist's assessment implies good awareness of psychological factors. The low sensitivity suggests a need for using a screening tool such as the PBSI, to guide management decisions. Trial registration : Clinical Trials NCT02265172, retrospectively registered June 10, 2014.

Purpose: To evaluate short-term effects of the PREVention of Sickness Absence for Musculoskeletal disorders (PREVSAM) model on sickness absence and patient-reported health outcomes., Methods: Patients with musculoskeletal disorders were randomised to rehabilitation according to PREVSAM or treatment as usual (TAU) in primary care. Sickness absence and patient-reported health outcomes were evaluated after three months in 254 participants., Results: The proportion of participants remaining in full- or part-time work were 86% in PREVSAM vs 78% in TAU ( p  = 0.097). The PREVSAM group had approximately four fewer sickness benefit days during three months from baseline ( p range 0.078-0.126). No statistically significant difference was found in self-reported sickness absence days (PREVSAM 12.4 vs TAU 14.5; p  = 0.634), nor were statistically significant differences between groups found in patient-reported health outcomes. Both groups showed significant improvements from baseline to three months, except for self-efficacy, and only the PREVSAM group showed significantly reduced depression symptoms., Conclusions: The findings suggest that for sickness absence, the PREVSAM model may have an advantage over TAU, although the difference did not reach statistical significance at the p  < 0.05 level, and similar positive effects on patient-reported health outcomes were found in both groups. Long-term effects must be evaluated before firm conclusions can be drawn.

Methods: Measurement of HGS with Jamar dynamometers was added to annual check-ups for patients with T2DM by diabetes nurses in primary care with feedback about normal values for age and sex in the intervention group. The control group had standard check-ups. Change in self-reported PA level was measured with questionnaires., Results: Seven clinics and 334 patients participated. The intervention led to similar effects on PA in both groups. Patients with T2DM had comparable HGS to the general public. Regression analyses showed statistically significantly higher HGS in the intervention group than in the control group at follow-up and no improvement in PA, HbA1c, or waist circumference. Increased HGS was found for older people, men, and people with normal-to-high inclusion HGS, while patients with low inclusion HGS reduced their strength levels., Conclusions: Measuring HGS and giving feedback to patients with T2DM can lead to increased HGS but does not seem to affect general PA level, HbA1c, or waist circumference. People over 65 years, men, and people with normal-to-high HGS were influenced positively by the intervention. Patients with low HGS may need personalised support to increase physical activity and improve function. ClinicalTrials registration:  NCT03693521.

Background: Musculoskeletal disorders are commonly treated in primary healthcare and may, if not treated adequately, entail a risk for long-term disability and sickness absence. A team-based rehabilitation intervention (PREVention of Sickness Absence for Musculoskeletal disorders, PREVSAM) was evaluated in a randomised controlled trial. The purpose of this study was to evaluate the process of implementing the PREVSAM model in primary care rehabilitation., Methods: This process evaluation was conducted alongside the trial, collecting quantitative and qualitative data to evaluate how the PREVSAM model was implemented, mechanisms of impact, and contextual factors. Acceptability, feasibility, appropriateness, adaptations, training and support, resources, recruitment, reach, retention, dose, fidelity, and readiness for change were investigated. Qualitative data were collected from healthcare professionals and patients., Results: Eight of 22 invited rehabilitation clinics (36%) and 28 of 54 healthcare professionals (52%) were included in the PREVSAM trial and this process evaluation. Of 507 eligible patients, 261 (51%) were included. Of those, 134 were randomised to the intervention and 129 (96%) were retained. Twelve healthcare professionals and 15 patients participated in the qualitative evaluations. The model's essential components; individual assessments and structured, team-based rehabilitation with clear division of responsibilities agreed in a joint health plan; were generally delivered according to protocol. The optional components early access to psychological treatment and workplace contact were delivered to a lesser extent. Perceived acceptability, feasibility, and appropriateness of the PREVSAM model were moderate to high. Several contextual barriers, in the form of missing prerequisites, affected the implementation. Qualitative data showed that the model, with its holistic view, was appreciated by both healthcare professionals and patients., Conclusions: This process evaluation suggests that PREVSAM is acceptable, feasible and appropriate for patients with MSDs reporting psychological risk factors associated with increased risk for sickness absence. While essential components were implemented with fidelity for most patients, optional components were not. This variability reflects the complexity of the model, its mandatory and optional components, contextual barriers, and the person-centred approach meeting individual patient needs. As all model components were not delivered to all patients, the intervention may have been too similar to treatment as usual to detect differences on a group level. A limitation of the study is that half of the participating rehabilitation clinics withdrew prematurely., (© 2024. The Author(s).)

A research-supported model to support schools' prevention of behavior problems and promotion of a positive school climate is school-wide positive behavior support (SW-PBS), in Scandinavia adapted into "positive behavior, interactions and learning environment in school" (PALS). Facilitators and barriers for achieving and sustaining a full implementation of PALS in a Swedish primary school context have not previously been studied. The purpose of this study was to explore school staff and administrators' experiences of implementing PALS in a municipal school district in the western region of Sweden. Using a qualitative focus group design, staff with roles in the implementation and school administrators (N = 22) representing 12 schools were asked about their experiences regarding facilitators and barriers for implementing PALS. Data were analyzed using qualitative content analyses involving a combination of inductive (data-driven) and deductive (theory-driven) approaches. In the deductive, final step, the inductively derived categories were associated with the Normalization process theory core constructs coherence, cognitive participation, collective action and reflexive monitoring. The analysis resulted in nine categories in which both facilitators and barriers were identified: alignment with school mission and values; building and strengthening relationships; shared staff engagement; administrators' commitment and leadership; support and resources for adopting PALS; changed experiences of PALS work over time; positive feedback sustains motivation; learning for quality improvement; and staff continuity throughout implementation. Findings indicate that staff and administrators experienced the implementation as predominantly positive, that PALS provides a structure for relationship-based work, and fits particularly well in primary school contexts. The facilitators and barriers identified provide valuable knowledge that can inform sustainable implementations of PALS in similar contexts., (© 2024 The Author(s). Scandinavian Journal of Psychology published by Scandinavian Psychological Associations and John Wiley & Sons Ltd.)

Aims: It has been suggested that nitrate-rich beetroot juice (BRJ) reduces blood pressure (BP) in various populations. We aimed to investigate the effect of BRJ on BP in adults with hypertension according to the European Society of Hypertension Guidelines (clinical BP ≥ 140/≥ 90 mmHg) and whether BRJ can be considered as an adjunct to hypertension drug treatment, by conducting a meta-analysis of randomized controlled trials., Data Synthesis: PubMed, SCOPUS, Medline Ovid, Cinahl, Cochrane Library and Web of Science were searched from inception until April 13, 2024 to identify randomized controlled trials of BRJ versus placebo, water, or no intake. Risk of bias was assessed using a standardized appraisal instrument from the Swedish Agency for Health Technology and Assessment of Social Services, which is based on the Cochrane risk-of-bias tool for randomized trials. The pooled BP effect size was calculated using random effects models and meta-regression. Certainty of evidence was assessed using GRADE. Eleven trials (349 patients) were included. BRJ yielded a significant reduction in clinical systolic BP compared with placebo mean difference (MD) -5.31 mmHg (95% CI -7.46, -3.16; I 2  = 64%, GRADE ⊕⊕OO). There was no significant effect on clinical diastolic BP or 24-h BP outcomes, and the heterogeneity was moderate to high., Conclusions: Daily ingestion of 200-800 mg of nitrate from BRJ may reduce clinical systolic BP in hypertensive individuals with no sign of development of tolerance. Certainty of evidence is low, and results should be interpreted with caution., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The Scandinavian Neurotrauma Committee guideline (SNC-16) was developed and published in 2016, to aid clinicians in management of pediatric head injuries in Scandinavian emergency departments (ED). The objective of this study was to explore determinants for use of the SNC-16 guideline by Swedish ED physicians., Methods: This is a nationwide, cross-sectional, web-based survey in Sweden. Using modified snowball sampling, physicians managing children in the ED were invited via e-mail to complete the validated Clinician Guideline Determinants Questionnaire between February and May, 2023. Baseline data, data on enablers and barriers for use of the SNC-16 guideline, and preferred routes for implementation and access of guidelines in general were collected and analyzed descriptively and exploratory with Chi-square and Fisher's tests., Results: Of 595 invitations, 198 emergency physicians completed the survey (effective response rate 33.3%). There was a high reported use of the SNC-16 guideline (149/195; 76.4%) and a strong belief in its benefits for the patients (188/197; 95.4% agreement). Respondents generally agreed with the guideline's content (187/197; 94.9%) and found it easy to use and navigate (188/197; 95.4%). Some respondents (53/197; 26.9%) perceived a lack of organizational support needed to use the guideline. Implementation tools may be improved as only 58.9% (116/197) agreed that the guideline includes such. Only 37.6% (74/197) of the respondents agreed that the guideline clearly describes the underlying evidence supporting the recommendation. Most respondents prefer to consult colleagues (178/198; 89.9%) and guidelines (149/198; 75.3%) to gain knowledge to guide clinical decision making. Four types of enablers for guideline use emerged from free-text answers: ease of use and implementation, alignment with local guidelines and practice, advantages for stakeholders, and practicality and accessibility. Barriers for guideline use were manifested as: organizational challenges, medical concerns, and practical concerns., Conclusions: The findings suggest high self-reported use of the SNC-16 guideline among Swedish ED physicians. In updated versions of the guideline, focus on improving implementation tools and descriptions of the underlying evidence may further facilitate adoption and adherence. Measures to improve organizational support for guideline use and involvement of patient representatives should also be considered., (© 2024. The Author(s).)

Background: Insufficient physical activity is a growing public health concern and is closely linked to obesity in both adults and children. Swedish physical activity on prescription (PAP) is effective in increasing physical activity levels in adults, but knowledge about how PAP is used in paediatric healthcare is lacking. Therefore, this study aimed to explore experiences of working with PAP for children with obesity amongst paediatric staff and managers., Methods: Seven focus group discussions with 26 participants from paediatric outpatient clinics in western Sweden were conducted. Data were analysed both inductively and deductively, framed by the Normalization Process Theory's four core constructs: coherence, cognitive participation, collective action, and reflexive monitoring., Results: The PAP work for children with obesity was experienced to be about helping children to become physically active, and less about losing weight. Identified barriers for using PAP were the non-uniform nature of the work and a perceived lack of guidelines. Collaboration with physiotherapists and physical activity organisers outside the organisation was identified as an important facilitator. An important contextual factor for implementing PAP is the collaboration between paediatric clinics and physical activity organisers. In the transition between these stakeholders, maintaining a family-centred approach when working with PAP was experienced as challenging., Conclusions: PAP is a well-known intervention that is inconsistently used for children with obesity. The intervention should include a family-centred approach for this patient group. It also needs to align better with existing collaborations with other healthcare units as well as with new forms of collaboration with physical activity organisers in the community., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Boman, Bernhardsson, Lundqvist, Melin and Lauruschkus.)

Background: Somatisation is a highly prevalent psychiatric syndrome in both women and men, in which psychological distress is manifested in physical symptoms without a medical explanation. Many patients with somatisation disorder are high healthcare utilisers, particularly at emergency departments. Unnecessary investigations and diagnostic operations occur frequently, which cause both patient suffering and a significant burden on the healthcare system. Emergency department physicians' awareness of somatisation and its manifestations has not previously been studied. This study aimed to investigate awareness about somatisation disorder among physicians working at emergency departments in western Sweden, and to explore differences between gender, specialty, and work experience., Methods: A web-based, cross-sectional survey consisting of six dichotomous questions about somatisation disorder was conducted, in December 2021 - January 2022, among licensed physicians of various specialties working at emergency departments in western Sweden. Descriptive analyses and comparative analyses were performed to investigate differences between gender, type of specialty, and years of practice. Data were analysed using chi 2 tests and Fisher's exact test., Results: Of the 526 eligible physicians who received the survey, 241 responded; response rate 45.8%. The majority of the respondents (56.4%) were women, and most (35.3%) were specialised in obstetrics/gynaecology. Average years of work experience was 11.1 (SD 8.7) years. Although 71% of respondents were aware of the diagnosis, only 7% knew the diagnostic criteria and only 6% had ever diagnosed a patient with somatisation disorder. Female physicians were more aware of underlying factors than their male colleagues (55.7% vs. 38.2%; p = .010). Type of specialty or years of practice did not affect awareness., Conclusions: Awareness of somatisation disorder is low among physicians working at emergency departments in western Sweden. The findings suggest a need to increase awareness and knowledge and provide training in diagnosing the condition, to ensure correct decisions and optimal patient management. Clinical guidelines need to be developed to support diagnosis, investigation, and treatment, in Sweden as well as internationally., (© 2024. The Author(s).)

Background: Although there is growing awareness that early childhood development programs are important for a sustainable society, there is a knowledge gap about how to implement such programs. Successful implementation requires attention to implementation drivers (competency, organization, and leadership) during all phases of the implementation. The purpose of this study was to describe cross-sectoral operational workgroups' perceptions of facilitators, barriers and solutions related to implementation drivers in the preparationphase of implementing an evidence-based early childhood home visiting program., Methods: Quantitative and qualitative data were collected from twenty-four participants, divided into 5 groups, during implementation planning workshops. The workshops were guided by a structured method informed by the principles of Motivational Interviewing and within a framework of implementation drivers. Groups sorted cards with statements representing implementation drivers according to perceptions of facilitators and barriers, and percentages were calculated for each type of implementation determinant, for each type of driver. The groups discussed their card sorting and wrote action plans to address barriers, yielding documentation that was analyzed using deductive qualitative content analysis., Results: A mixed-methods analysis resulted identification of facilitators, barriers, unknowns and solutions in two to three subcategories under each main category of implementation driver. A competent and confident workforce, and enthusiasm and commitment were key facilitators. Key barriers were unclear roles and responsibilities, and insufficient articulation of local vision and goals. Many factors were described as yet unknown. Specific solutions were generated to support the implementation., Conclusions: Our study furthers the scientific understanding of how to take evidence-based early childhood programs from research to practice within an implementation drivers framework. Facilitators, barriers and solutions in key areas during the preparation phase were identified with the help of a novel tool. The results provide useful knowledge for decision makers and organizations preparing similar initiatives in communities striving to attain sustainable development goals., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Lundgren, Nilses, Eckerdal and Bernhardsson.)

Introduction: Swedish Physical Activity on Prescription (PAP) has been shown to increase physical activity levels, which is known to lead to positive health effects. PAP is being implemented in Swedish healthcare to various extents. However, there is a lack of knowledge about how Swedish general practitioners (GPs) work with PAP and what hinders and facilitates wider implementation., Aims: This study aimed to survey GPs' use and views of PAP, identify barriers and facilitators for implementing PAP, and explore associations to gender, practice location, and experience., Methods: The study was framed by the Normalization Process Theory. A survey was sent to 463 GPs at 69 different healthcare centres in Region Västra Götaland. Data were analysed using multiple logistic and linear regressions., Results: A total of 143 GPs completed the survey (response rate 31%). Views on PAP were generally positive amongst respondents, but only 27% reported using PAP regularly. The most prominent reported barriers were insufficient training and resources. Positive views and willingness to collaborate in using PAP were identified as facilitators. Responding GPs in Gothenburg used PAP more often (OR 6.4; 95% CI 2.7-14.8) and were significantly more positive to the method than GPs in other areas of the region. GPs with more than 10 years of practice used PAP more often (OR 2.5; 95% CI 1.1-6.0) than less experienced GPs. Few of the investigated variables were associated with gender., Conclusions: The positive views amongst responding GPs are helpful, but more education, training and resources are needed for successful implementation of PAP in Swedish primary health care.

Background: There is overwhelming evidence for the preventive effects of regular physical activity and healthy eating habits on the risk for developing a non-communicable disease (NCD). Increasing attention has been paid to community-wide approaches in the battle against NCDs. Communities can create supportive policies, modify physical environments, and foster local stakeholder engagement through intersectoral collaboration to encourage communities to support healthy lifestyles. The Pep initiative is based on intersectoral community-wide collaboration among Sweden's municipalities. Primary targets are municipality professionals who work with children and young people as well as parents of children <18 years. The goal is to spread knowledge and create commitment to children's and young people's health with a special focus on physical activity and healthy eating habits to facilitate and support a healthy lifestyle. The overarching aim of the research project described in this study protocol is to investigate factors that influence the implementation of the Pep initiative in Sweden, to inform tailored implementation strategies addressing the needs and local prerequisites of the different municipalities., Methods: The project includes a qualitative and a quantitative study and is framed by a theoretical model involving four complementary forms of knowledge, explicitly recognized in the Pep initiative: knowledge about the issue; knowledge about interventions; knowledge about the context; and knowledge about implementation. Study 1 is a focus group study exploring barriers and facilitators for implementing the Pep initiative. The study will be carried out in six municipalities, selected purposively to provide wide variation in municipality characteristics, including population size and geographical location. Data will be analyzed using thematic analysis. Study 2 is a cross-sectional web-based survey investigating the implementability of the Pep initiative in Sweden's 290 municipalities. Conditions for implementing different areas of the Pep initiative will be examined in terms of the acceptability, appropriateness, and feasibility, three predictors of implementation success. Data will be analyzed using non-parametric statistics., Discussion: The findings of the two studies will increase understanding of the prerequisites for implementing the Pep initiative in Swedish municipalities, which will provide valuable input into how implementation of the Pep initiative can best be facilitated in the different municipality settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Leijon, Algotson, Bernhardsson, Ekholm, Ersberg, Höök, Klüft, Müssener, Garås and Nilsen.)

Family Check-up (FCU) was introduced in Sweden more than a decade ago. Little is known about what parents experience as FCU's key mechanisms leading to changes in parenting. The aim of this study was to investigate Swedish parents' satisfaction with FCU, and their experiences of facilitators and barriers for making changes in their parenting. A mixed methods approach was employed using a parent satisfaction questionnaire (n = 77) and focus groups (n = 15). General satisfaction with FCU was adequate, with an average rating of 4 on a five-point scale (range 3.1-4.6). The analysis of quantitative and qualitative data resulted in eight themes representing facilitators and four themes representing barriers, organized into three categories: (1) access and engagement; (2) therapeutic process; and (3) program components. Ease of access to FCU facilitated initial engagement. Individual tailoring and access to FCU during different phases of change facilitated sustained engagement and change. Therapeutic process facilitators were a meaningful, supportive relationship with the provider, psychological benefits for parents and benefits for the whole family. Program components that facilitated change in parenting were new learning of parenting strategies and use of helpful techniques such as videotaping and home practice. Negative experiences with service systems prior to starting FCU, parent psychological barriers, and parent-provider mismatch were described as potential barriers. Some parents desired other program formats that were not offered, and some felt that new learning was insufficient to improve child behavior. Understanding the parent perspective can contribute to successful future work with implementing FCU., (© 2023 Scandinavian Psychological Associations and John Wiley & Sons Ltd.)

Background: This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness., Methods: Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE., Results: Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment., Discussion: Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access., Trial Registration: The review was registered in the PROSPERO database, CRD42021277624., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Bernhardsson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Many children with intellectual developmental disorders are insufficiently physically active and do not reach recommendations for physical activity. Pediatric healthcare providers play a key role in addressing these children's needs, including promoting interventions for physical activity., Aim: To explore pediatric healthcare providers' perceived needs, barriers, and facilitators for promoting physical activity for children with intellectual developmental disorders., Methods: Semi-structured focus groups, analyzed using qualitative content analysis. Sixteen healthcare providers participated., Results: Main findings are the importance of parental support and engagement, need for structure, and stakeholder collaboration to bridge the gap between pediatric organizations and external stakeholders., Conclusion: The study highlights the need for developing and implementing strategies to promote physical activity for children with intellectual developmental disorders in pediatric health care, and for producing guidelines regarding physical activity interventions for this vulnerable group.

Background: Physical inactivity is a main driver of childhood obesity that tracks into adulthood, making it crucial to address early in life. Swedish physical activity on prescription (PAP) is an effective intervention for increasing physical activity levels in adults and is being implemented in primary care in Sweden. Before implementing PAP for children, both intervention effectiveness and implementation prerequisites need to be examined. Framed by the Normalization Process Theory (NPT) domains, this study aimed to investigate perceptions of PAP amongst paediatric staff and managers working with children with obesity, as well as acceptability, appropriateness, feasibility, and barriers and facilitators for implementing PAP in paediatric health care., Methods: Staff and managers in 28 paediatric outpatient clinics in western Sweden were surveyed using validated implementation instruments and open-ended questions. Data were analysed using Mann-Whitney U tests and Kruskal-Wallis tests. Qualitative data were categorised into NPT domains., Results: The survey response rate was 54% (125/229). Most respondents (82%) reported PAP to be familiar and many (56%) perceived it as a normal part of work; nurses and physiotherapists to a greater extent ( p  < 0.001). This was anticipated to increase in the future (82%), especially amongst those with the longest work experience ( p  = 0.012). Respondents reported seeing the potential value in their work with PAP (77%), being open to working in new ways to use PAP (94%), and having confidence in their colleagues' ability to use PAP (77%). Barriers and facilitators were found in all the NPT domains, mainly collective action and reflexive monitoring, where, for example, inadequacies of education, resources, and research on PAP for children were reported as barriers. Most respondents agreed that PAP was acceptable, appropriate, and feasible (71% to 88%)., Conclusions: PAP is familiar and perceived as an acceptable, appropriate, and feasible intervention, and by many viewed as a normal part of clinical routines in paediatric outpatient clinics in western Sweden, especially by physiotherapists and nurses. Barriers and faciliators are mainly related to collective action and reflexive monitoring. The wide acceptance demonstrates receptiveness to PAP as an intervention to promote an active lifestyle for children with obesity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Boman, Bernhardsson, Lauruschkus, Lundqvist and Melin.)

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Background: Physical inactivity is a main cause of childhood obesity which tracks into adulthood obesity, making it important to address early in life. Physical activity on prescription (PAP) is an evidence-based intervention that has shown good effect on physical activity levels in adults, but has not been evaluated in children with obesity. This project aims to evaluate the prerequisites, determinants, and feasibility of implementing PAP adapted to children with obesity and to explore children's, parents', and healthcare providers' experiences of PAP., Methods: In the first phase of the project, healthcare providers and managers from 26 paediatric clinics in Region Västra Götaland, Sweden, will be invited to participate in a web-based survey and a subset of this sample for a focus group study. Findings from these two data collections will form the basis for adaptation of PAP to the target group and context. In a second phase, this adapted PAP intervention will be evaluated in a clinical study in a sample of approximately 60 children with obesity (ISO-BMI > 30) between 6 and 12 years of age and one of their parents/legal guardians. Implementation process and clinical outcomes will be assessed pre- and post-intervention and at 8 and 12 months' follow-up. Implementation outcomes are the four core constructs of the Normalization Process Theory; coherence, cognitive participation, collective action, and reflexive monitoring; and appropriateness, acceptability, and feasibility of the PAP intervention. Additional implementation process outcomes are recruitment and attrition rates, intervention fidelity, dose, and adherence. Clinical outcomes are physical activity pattern, BMI, metabolic risk factors, health-related quality of life, sleep, and self-efficacy and motivation for physical activity. Lastly, we will explore the perspectives of children and parents in semi-structured interviews. Design and analysis of the included studies are guided by the Normalization Process Theory., Discussion: This project will provide new knowledge regarding the feasibility of PAP for children with obesity and about whether and how an evidence-based intervention can be fitted and adapted to new contexts and populations. The results may inform a larger scale trial and future implementation and may enhance the role of PAP in the management of obesity in paediatric health care in Sweden., Trial Registration: ClinicalTrials.gov Identifier: NCT04847271 , registered 14 April 2021., (© 2022. The Author(s).)

Background: The aim of this systematic review was to evaluate the assessment of trabecular bone patterns in dental radiographs, for fracture risk prediction, compared with the current diagnostic methods., Methods: The PRISMA guidelines were followed. According to predefined inclusion criteria (PICO), literature searches were focussed on published studies with analyses of trabecular bone patterns on intraoral and/or in panoramic radiographs, compared with Dual X-ray Absorptiometry (DXA) and/or Fracture Risk Assessment Tool (FRAX), with the outcomes; fracture and/or sensitivity and specificity for osteoporosis prediction. The included studies were quality-assessed using the QUADAS-2 tool and the certainties of evidence was assessed using the GRADE approach., Results: The literature searches identified 2913 articles, whereas three were found to meet the inclusion criteria. Two longitudinal cohort studies evaluated the use of trabecular bone patterns to predict bone fractures. In one of the studies, the relative risk of fracture was significantly higher for women with sparse bone pattern, identified by visual assessment of dental radiographs, and in the other study by digital software assessment. Visual assessment in the second study did not show significant results. The cross-sectional study of digital analyses of trabecular bone patterns in relation to osteoporosis reported a sensitivity of 0.70 and a specificity of 0.69., Conclusion: Based on low certainty of evidence, trabecular bone evaluation on dental radiographs may predict fractures in adults without a prior diagnosis of osteoporosis, and based on very low certainty of evidence, it is uncertain whether digital image analyses of trabecular bone can predict osteoporosis.

Background: There is no consensus for when publicly funded breast reduction is indicated and recommendations in guidelines vary greatly, indicating a lack of evidence and unequal access. The primary aim of this review was to examine risks and benefits of breast reduction to treat breast hypertrophy. Secondary aims were to examine how the studies defined breast hypertrophy and indications for a breast reduction., Methods: A systematic literature search was conducted in PubMed, MEDLINE All, Embase, the Cochrane Library, and PsycInfo. The included articles were critically appraised, and certainty of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible., Results: Fifteen articles were included; eight reporting findings from four randomised controlled trials, three non-randomised controlled studies, three case series, and one qualitative study. Most studies had serious study limitations and problems with directness. Few of the studies defined breast hypertrophy. The studies showed significantly improved health-related quality of life and sexuality-related outcomes in patients who had undergone breast reduction compared with controls, as well as reduced depressive symptoms, levels of anxiety and pain. Most effect sizes exceeded the reported minimal important difference for the scale. Certainty of evidence for the outcomes above is low (GRADE ⊕ ⊕). Although four studies reported significantly improved physical function, the effect is uncertain (very low certainty of evidence, GRADE ⊕). None of the included studies reported data regarding work ability or sick leave. Three case series reported a 30-day mortality of zero. Reported major complications after breast reduction ranged from 2.4 to 14% and minor complications from 2.4 to 69%., Conclusion: There is a lack of high-quality studies evaluating the results of breast reduction. A breast reduction may have positive psychological and physical effects for women, but it is unclear which women benefit the most and which women should be offered a breast reduction in the public healthcare system. Several priorities for further research have been identified., Pre-Registration: The study is based on a Health Technology Assessment report, pre-registered and then published on the website of The Regional HTA Centre of Region Västra Götaland, Sweden., (© 2021. The Author(s).)

Background: Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics., Methods: Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups., Results: Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours., Conclusions: Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Stress-related mental disorders contribute to work disabilities globally and are a common cause for sick leave. Nature-based rehabilitation (NBR) is a multi-disciplinary approach offered to this patient group on a limited scale. Qualitative studies provide insight into patients' experiences of NBR, and there is a need to synthesize and assess the certainty of evidence for patient-experienced benefits. The aim was to identify, appraise, and synthesize studies reporting experiences and perceived benefits of participation in multidisciplinary, group-based NBR of adult patients with long-standing stress-related mental disorders. PubMed, Embase, CINAHL, AMED, APA PsycInfo, and the Cochrane Library were searched from inception to December 2020. Reference lists of relevant publications were searched. After title and abstract screening, full-text articles were retrieved and assessed for inclusion. The methodological quality of the included studies was assessed, and certainty of evidence was appraised according to CERQual. The search yielded 362 unique records; 19 full-text publications were assessed for eligibility, and 5 studies were included in the synthesis. The studies were considered relevant regarding context, population, and intervention, and quality was generally assessed as moderate to high. Extracted texts were inductively coded and organized into 16 descriptive themes and 4 broad, analytical themes: Instilling calm and joy; Needs being met; Gaining new insights; and Personal growth. Experiences and perceived benefits of participating in NBR and spending time in a nature environment were described as positive for recovery. Nine of the descriptive themes were based on explicit results from at least four of the five studies. Confidence in the evidence of the qualitative findings ranged from moderate to low. Moderate-to-low certainty evidence from the included studies suggests that patients with long-standing stress-related mental disorders experience positive health effects from participating in NBR.

Introduction: Somatization, defined as a number of medically unexplained physical symptoms for many years, is a resource-intensive condition with much suffering. Adult somatization has been linked to childhood trauma in both men and women. Among women, sexual trauma affects somatization level to a greater extent than nonsexual trauma. Early diagnosis of a somatization disorder would be of great help for both patients and society. The purpose of this scoping review is to map and summarize the literature on symptoms within somatization in women who have been sexually abused, and investigate if any specific symptom can be linked to previous sexual abuse., Material and Methods: A scoping review methodology was used. The databases PubMed, PsycINFO, and the Cochrane Library were searched for original qualitative and quantitative research published between 2008 and 2019 that matched the objectives of the review., Results: The database search identified 195 articles, of which 43 were retrieved in full text. Seven articles were included, involving 2076 women. All studies were quantitative. The included studies were heterogeneous. Four studies showed inconsistent findings regarding a link between sexual abuse and chronic or acute pain. Two studies showed an association between sexual abuse and increased incidence of somatic symptoms. One study showed an association between sexual abuse and symptoms of irritable bowel syndrome. No specific somatic symptoms in somatization were identifiable within the scope of this study., Conclusions: This is to our knowledge the first scoping review on sexual abuse and symptoms of somatization. The findings suggest a link between sexual abuse and somatic symptoms, but the identified association with pain and irritable bowel syndrome is inconsistent. No studies have clearly identified specific symptoms within somatization associated with sexual abuse. Qualitative research on the topic was identified as a knowledge gap., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Purpose: Despite growth in rehabilitation research, implementing research findings into rehabilitation practice has been slow. This creates inequities for patients and is an ethical issue. However, methods to investigate and facilitate evidence implementation are being developed. This paper aims to make these methods relevant and accessible for rehabilitation researchers and practitioners. Methods: Rehabilitation practice is varied and complex and occurs within multilevel healthcare systems. Using a "road map" analogy, we describe how implementation concepts and theories can inform implementation strategies in rehabilitation. The roadmap involves a staged journey that considers: the nature of evidence; context for implementation; navigation tools for implementation; strategies to facilitate implementation; evaluation of implementation outcomes; and sustainability of implementation. We have developed a model to illustrate the journey, and four case studies exemplify implementation stages in rehabilitation settings. Results and Conclusions: Effective implementation strategies for the complex world of rehabilitation are urgently required. The journey we describe unpacks that complexity to provide a template for effective implementation, to facilitate translation of the growing evidence base in rehabilitation into improved patient outcomes. It emphasizes the importance of understanding context and application of relevant theory, and highlights areas which should be targeted in new implementation research in rehabilitation.Implications for rehabilitationEffective implementation of research evidence into rehabilitation practice has many interconnected steps and a roadmap analogy is helpful in defining them.Understanding context for implementation is critically important and using theory can facilitate development of understanding.Research methods for implementation in rehabilitation should be carefully selected and outcomes should evaluate implementation success as well as clinical change.Sustainability requires regular revisiting of the interconnected steps.

Background: Acute low back pain is associated with pain and disability, but symptoms are often self-healing. The effectiveness of exercise therapy for acute low back pain remains uncertain with conflicting evidence from systematic reviews. The aim of this systematic review of systematic reviews was to assess the overall certainty of evidence for the effects of exercise therapy, compared with other interventions, on pain, disability, recurrence, and adverse effects in adult patients with acute low back pain., Methods: PubMed, the Cochrane library, CINAHL, PEDro, Open Grey, Web of Science, and PROSPERO were searched for systematic reviews of randomized controlled trials. Methodological quality was assessed independently by two authors using AMSTAR. Meta-analyses were performed if possible, using data from the original studies. Data for pain, disability, recurrence, and adverse effects were analyzed. Certainty of evidence was assessed using GRADE., Results: The searches retrieved 2602 records, of which 134 publications were selected for full-text screening. Twenty-four reviews were included, in which 21 randomized controlled trials (n = 2685) presented data for an acute population, related to 69 comparisons. Overlap was high, 76%, with a corrected covered area of 0.14. Methodological quality varied from low to high. Exercise therapy was categorized into general exercise therapy, stabilization exercise, and McKenzie therapy. No important difference in pain or disability was evident when exercise therapy was compared with sham ultrasound, nor for the comparators usual care, spinal manipulative therapy, advice to stay active, and educational booklet. Neither McKenzie therapy nor stabilization exercise yielded any important difference in effects compared with other types of exercise therapy. Certainty of evidence varied from very low to moderate., Conclusions: The findings suggest very low to moderate certainty of evidence that exercise therapy may result in little or no important difference in pain or disability, compared with other interventions, in adult patients with acute low back pain. A limitation of this systematic review is that some included reviews were of low quality. When implementing findings of this systematic review in clinical practice, patients' preferences and the clinician's expertise also should be considered, to determine if and when exercise therapy should be the intervention of choice., Systematic Review Registration: PROSPERO: CRD46146, available at: https://www.crd.york.ac.uk/PROSPERO/display&#95;record.php?RecordID=46146 .

Background: Insomnia is a common diagnosis among patients in psychiatric health care and effective treatments are highly demanded. Previous research suggests that internet-delivered cognitive behavioural therapy for insomnia (ICBT-i) is helpful for a variety of patients and may be effective for psychiatric health care patients. Little is known about implementation of ICBT-i in psychiatric health care. The aim of this study was to explore experiences among therapists and managers who participated in a pilot implementation of ICBT-i in outpatient psychiatric health care, and to identify determinants for the implementation., Methods: Semi-structured interviews were conducted with 7 therapists and 5 managers working in outpatient psychiatric health care and directly involved with the pilot implementation. Data were analysed using qualitative content analysis guided by the NASSS framework, combining inductive and deductive approaches., Results: The analysis revealed 32 facilitators, 21 barriers, and 2 determinants that were both a barrier and a facilitator, organised in 1-5 themes under each of the 7 NASSS domains. Key facilitators included: meeting a demand for treatment options with the ICBT-i programme, the experienced benefits of ICBT-i as a treatment option for insomnia, training and support, engagement and support from managers and the wider system, and a long-term organisation for maintenance of the technology. Key barriers included: low interest in ICBT-i among therapists, difficulty in recruiting patients, perceived low ability in therapists to deliver treatment online, technical problems, and therapists' competing demands leading to low priority of ICBT-i. Complexity analysis assessed two NASSS domains as simple, four as complicated, and one as complex., Conclusions: The study contributes new knowledge and insights into the implementation process of ICBT-i in psychiatric health care. Our findings highlight the importance of providing training, support, and guidance in online treatment for therapists when implementing a technological innovation. Technical problems should be minimised and the maintenance and demand-side value for the technology must be clear. Support from managers at all levels is crucial, particularly support to therapists in everyday prioritisation among competing demands. Besides taking the identified determinants into account, managing complexity is important for successful scale-up implementation.

Background: Post-traumatic stress disorder (PTSD) is debilitating for patients and society. There are a number of treatment methods albeit not all patients respond to these and an interesting method using electroencephalography-based neurofeedback (EEG-NF) has become more prominent in recent years. This systematic review aimed to assess whether EEG-NF, compared with sham NF, other treatment, or no treatment, is effective for PTSD. Primary outcomes were self-harm, PTSD symptoms, level of functioning and health-related quality of life., Methods: Systematic literature searches for randomized controlled trials (RCTs) were conducted in six databases. Random effects meta-analysis was performed. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation., Results: Four RCTs were included (123 participants). Suicidal thoughts were significantly reduced after EEG-NF compared with a waiting list in a small study. PTSD symptoms were assessed in all studies with different instruments. Results were consistently in favor of EEG-NF with large effect sizes (standardized mean difference -2.30 (95% confidence interval: -4.37 to -0.24). One study reported significantly improved level of executive functioning and one study a reduction in use of psychotropic medication. Complications were scarcely reported. Certainty of evidence was assessed as very low for the four assessed outcomes., Conclusions: Based on four RCTs, with several study limitations and imprecision, it is uncertain whether EEG-NF reduces suicidal thoughts, PTSD symptoms, medication use, or improves function. Although all studies showed promising results, further studies are needed to increase the certainty of evidence.

Background: Subacromial impingement syndrome is a common problem in primary healthcare. It often include tendinopathy. While exercise therapy is effective for this condition, it is not clear which type of exercise is the most effective. Eccentric exercises has proven effective for treating similar tendinopathies in the lower extremities. The aim of this systematic review was therefore to investigate the effects of eccentric exercise on pain and function in patients with subacromial impingement syndrome compared with other exercise regimens or interventions. A secondary aim was to describe the included components of the various eccentric exercise regimens that have been studied., Methods: Systematic searches of PubMed, Cochrane Library and PEDro by two independent authors. Included studies were assessed using the PEDro scale for quality and the Cochrane scale for clinical relevance by two independent authors. Data were combined in meta-analyses. GRADE was applied to assess the certainty of evidence., Results: Sixty-eight records were identified. Seven studies (eight articles) were included, six were meta-analysed (n = 281). Included studies were of moderate quality (median PEDro score 7, range 5-8). Post-treatment pain was significantly lower after eccentric exercise compared with other exercise: MD -12.3 (95% CI - 17.8 to - 6.8, I 2  = 7%, p < 0.001), but this difference was not clinically important. Eccentric exercise provided no significant post-treatment improvement in function compared with other exercise: SMD -0.10 (95% CI - 0.79 to 0.58, I 2  = 85%, p = 0.76). Painful eccentric exercise showed no significant difference compared to pain-free eccentric exercise. Eccentric training regimes showed both similarities and diversity. Intervention duration of 6-8 weeks was almost as effective as 12 weeks., Conclusions: Evidence of low certainty suggests that eccentric exercise may provide a small but likely not clinically important reduction in pain compared with other types of exercise in patients with subacromial impingement syndrome. It is uncertain whether eccentric exercise improves function more than other types of exercise (very low certainty of evidence). Methodological limitations of existing studies make these findings susceptible to change in the future., Trial Registration: PROSPERO CRD42019126917 , date of registration: 29-03-2019.

Objectives: The purpose of this research was to generate and validate a questionnaire that identifies determinants of guideline use from the clinician perspective., Study Design and Setting: From January 2017 to March 2018, a seven-member six-country multidisciplinary team used a five-step multimethod design to search for and compile determinant frameworks, map items to determinants (content validity), select the best items for each determinant (content validity), refine wording of determinants and items (face validity), merge or separate items (construct validity), and review the final questionnaire., Results: The Clinician Guideline Determinants Questionnaire includes four sections: clinician demographic information (including two determinants: attitudes about/experience with guidelines), 26 close-ended items reflecting clinician- and guideline-specific determinants, four open-ended items reflecting enablers and barriers perceived as most important, and three items on learning style (preferred sources of guideline information)., Conclusion: The Clinician Guideline Determinants Questionnaire is a comprehensive, validated instrument that addresses multiple potential determinants specific to guideline use from a clinician perspective. The Questionnaire can be used at multiple time points in the guideline development cycle to assess determinants of the use of new, updated, or adapted guidelines and before and after interventions to assess their impact on the determinants of guideline use. In future research, we will establish psychometric properties of the new questionnaire., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)