An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis

Efficacy of mobile health interventions in the conservative management of chronic low back pain in low- and middle-income countries: a systematic review, meta-analysis, and trial sequential analysis

Chronic low back pain (CLBP) is a major global health issue, particularly severe in low- and middle-income countries (LMICs), where health care resources and accessibility are limited. Mobile health (mHealth) interventions offer a promising solution by leveraging technology to deliver health care services remotely. This review aims to evaluate the effectiveness of mHealth interventions in managing CLBP in LMICs. A comprehensive search of electronic databases was performed for studies published until June 2024, evaluating mHealth interventions for CLBP in LMICs. Primary outcomes measured were pain intensity and disability, while secondary outcomes included quality of life (QoL). Risk of bias was assessed using Cochrane risk-of-bias tool (RoB2), and quality of evidence was evaluated using GRADE. Robustness of meta-analysis results was assessed via trial sequential analysis (TSA). Seven studies met the inclusion criteria. The mHealth interventions significantly reduced the overall pain intensity (MD = -1.11, 95% CI: -1.75, -0.46) and disability (MD = -6.59, 95% CI: -10.65, -2.54). Subgroup analysis indicated greater effectiveness of short-term interventions (<6 weeks) in reducing pain and Oswestry disability index (ODI) vs long-term interventions (>6 weeks). mHealth interventions notably reduced pain and ODI scores vs unsupervised programs but showed no significant difference compared to in-person programs. The z-score line remained within TSA boundaries. mHealth interventions show potential in reducing pain and disability among patients with CLBP in LMICs, although with inconclusive impact on QoL. The high heterogeneity and limited number of studies underscore the need for further research with greater sample size to validate these findings and explore the long-term benefits and implementation challenges of mHealth in resource-constrained settings.

Implementation-effectiveness of the power over pain portal for patients awaiting a tertiary care consultation for chronic pain: A pilot feasibility study

Background

The Power Over Pain (POP) Portal is a digital platform that provides people living with pain (PLWP) flexible access to chronic pain self-management resources.

Aims

To (1) determine the feasibility of an adequately-powered multisite trial of the POP Portal in tertiary settings; (2) understand the acceptability and usability of the POP Portal; and (3) explore clinical effectiveness among PLWP awaiting a first visit to a tertiary care pain clinic.

Methods

Mixed-methods pilot-feasibility study to inform a future definitive trial. Feasibility was assessed using recruitment and retention rates. Acceptability, usability, and patient outcomes were measured using validated surveys completed at baseline and 3-month follow-up, and semistructured interviews conducted after 3-month follow-up.

Results

Forty-one participants completed follow-up surveys and nine completed interviews. We reached a recruitment and retention rate of 83.75% and 61.19%, respectively. There was a reduction in pain interference (p = .024) and belief in a medical cure (p = .033) after using POP for 3 months. Surveys and interviews indicate PLWP were satisfied with the POP Portal, and it had good usability. Some participants indicated that POP was overwhelming, and certain resources were difficult to access, indicating that modifications could be made to improve ease of use.

Conclusions

The POP Portal was deemed acceptable with good usability; however, modification may be made for improvement. A definitive trial can proceed with enhancements to the portal, modification of the protocol, and close monitoring.

Transforming Chronic Pain Care Through Telemedicine: An Italian Perspective

Chronic pain (CP) is a complex and debilitating condition that significantly impairs quality of life and imposes a high burden on healthcare systems. This study aims to evaluate the impact of telemedicine on chronic pain management in cancer survivors with complex CP. Our multicenter retrospective investigation of cancer survivors with complex CP included 100 patients (median age 65 years, 62% female). Pain, disability, and self-perceived health status were assessed using the Numeric Rating Scale (NRS), Brief Pain Inventory (BPI), Oswestry Disability Index (ODI), and the EuroQolfive-dimension five-level (EQ-5D-5L) questionnaire. The most common diagnoses were neuropathic pain (54%) and complex chronic pain (32%). Significant clinical improvements were observed after six months of telemedicine intervention (all p < 0.001). NRS scores improved by more than four points in 77% of patients, BPI Worst Pain Scores decreased by four points in 52% and by five points in 28% of patients. All patients' disability levels improved from severe (median ODI score of 52) to moderate (median ODI score of 30). Self-perceived health status improved from 40 to 60 on the EQ-5D-5L scale. Telemedicine interventions significantly reduced pain intensity, decreased disability levels, and enhanced quality of life in chronic pain patients. These findings underscore the transformative potential of telemedicine in chronic pain management and support its broader integration into medical practice.

Effects of a Smartphone App-Based Intervention on Rheumatoid Arthritis Self-Management Efficacy: A Randomized Controlled Trial

BACKGROUND

Self-management programs can help patients with rheumatoid arthritis develop strategies to address their disease-related problems. However, accessibility to traditional self-management programs is often limited.

PURPOSE

This study was developed to assess the effectiveness, feasibility, and acceptability of a smartphone-delivered self-management program application (app) for adults with rheumatoid arthritis.

METHODS

A two-arm (intervention vs. control) randomized controlled trial was used. Adult patients with rheumatoid arthritis were recruited from the rheumatology departments of a medical center. Study enrollment capabilities were limited by current pandemic restrictions. The patients who met the inclusion criteria and agreed to participate (N = 46) were enrolled as participants and randomly assigned either to the intervention group (n = 25), which received instructions on the use of a smartphone app designed to facilitate the self-management of rheumatoid arthritis, or to the control group (n = 21), which received instructions on related self-management only. The outcome variables were assessed at baseline and at 8 and 12 weeks. Differences in between-group outcomes over time were analyzed using generalized estimating equations. Feasibility and acceptability were also evaluated. Data were collected between August 1, 2020, and July 31, 2022.

RESULTS

At baseline, no differences were detected between the two groups in terms of the demographic and disease characteristics of concern. Outcome measures for the intervention group improved significantly more than the control group for self-efficacy of pain at 8 weeks (B = 6.39, p < .05) and for both of self-efficacy of pain and self-management behavior at 12 weeks (B = 9.16, p < .05, and B = 4.25, p < .001, respectively). Factors related to app ease of use included limiting pop-ups and windows and having no time restrictions. Most of the participants reported the app as acceptable and easy to use, although challenges relating to using technology limited the usability of the app for some.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The smartphone app was shown to improve self-efficacy of pain and self-management behaviors. However, an accurate assessment of the effectiveness of the app and generalizability of the findings is limited by the smaller-than-desired sample size due to the COVID-19 pandemic and technological challenges. A greater understanding of how to overcome technological challenges is needed to optimize the delivery of self-management programs via smartphone-based apps. Studies reevaluating this app on a larger sample size should be conducted.

Innovative Applications of Telemedicine and Other Digital Health Solutions in Pain Management: A Literature Review

Since the COVID-19 pandemic, healthcare systems are facing extraordinary challenges. Our approaches to medicine have changed and created a whole new generation of people who have chronic pain. Various medical services were postponed. The pandemic significantly impacted the bio-psychosocial model of pain and the management of chronic pain. These new challenges affected millions of patients worldwide, with more burden on patients with chronic pain. Telemedicine and digital health rather than traditional office visits have become essential tools for communications, resulting in an unmatched surge in telehealth adoption. This new approach facilitated the remote treatment and follow-up of patients who have difficulty to access the healthcare services, particularly patients with chronic pain and those who were receiving regular controlled medications. An extensive computer search was conducted, during the period (from January 2014 to March 2024), and included literature from PubMed, Scopus, MEDLINE, and Google scholar. According to preset inclusion and exclusion criteria, a total of 38 articles have been included in this review article. This literature review focuses on the innovation of telemedicine and digital health in pain management, especially in the context of the challenges posed by the COVID-19 pandemic. The manuscript provides a comprehensive overview of telemedicine and digital communications, their evolution, and their significance in healthcare. It also emphasizes the benefits, challenges, limitations, and the ethical concerns of telemedicine in pain management after the COVID-19 pandemic. Furthermore, the document explores the different modes of the telecommunications and discusses the future directions of the digital health technology.

eHealth-Integrated Psychosocial and Physical Interventions for Chronic Pain in Older Adults: Scoping Review

BACKGROUND

Chronic noncancer pain (CNCP) is highly present among older adults, affecting their physical, psychological, and social functioning. A biopsychosocial multimodal approach to CNCP management is currently extensively suggested by international clinical practice guidelines. Recently, the growing development and application of eHealth within pain management has yielded encouraging results in terms of effectiveness and feasibility; however, its use among the older population remains underexamined.

OBJECTIVE

The overall aim of this scoping review was to systematically map existing literature about eHealth multimodal interventions (including both physical and psychosocial components) targeting older adults with CNCP.

METHODS

This review adhered to the JBI methodology, a protocol was a priori registered as a preprint on the medRxiv platform, and the results were reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. Four electronic databases (PubMed, Cochrane Central Register of Controlled Trials, Web of Science, and PsycINFO) were systematically searched for relevant articles. Studies were included if they reported on multimodal interventions (including both physical and psychosocial components) delivered through any eHealth modality to an older population with any type of CNCP. Two reviewers selected the studies: first by screening titles and abstracts and second by screening full-text articles. The quality of the included studies was evaluated using the Quality Assessment Tool for Studies with Diverse Designs. The results of the studies were summarized narratively.

RESULTS

A total of 9 studies (n=6, 67% published between 2021 and 2023) with quality rated as medium to high were included, of which 7 (78%) were randomized controlled trials (n=5, 71% were pilot and feasibility studies). All the included studies evaluated self-management interventions, most of them (n=7, 78%) specifically designed for older adults. The participants were aged between 65 and 75 years on average (mean 68.5, SD 3.5 y) and had been diagnosed with different types of CNCP (eg, osteoarthritis and chronic low back pain). Most of the included studies (5/9, 56%) involved the use of multiple eHealth modalities, with a higher use of web-based programs and video consulting. Only 1 (11%) of the 9 studies involved a virtual reality-based intervention. The evaluated interventions showed signs of effectiveness in the targeted biopsychosocial outcomes, and the participants' engagement and ratings of satisfaction were generally positive. However, several research gaps were identified and discussed.

CONCLUSIONS

Overall, of late, there has been a growing interest in the potential that eHealth multimodal interventions offer in terms of improving pain, physical, and psychosocial outcomes in older adults with CNCP. However, existing literature on this topic still seems scarce and highly heterogeneous, with few proper randomized controlled trials, precluding robust conclusions. Several gaps emerged in terms of the older population considered and the lack of evaluation of comorbidities.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1101/2023.07.27.23293235.

A digital health intervention to support patients with chronic pain during prescription opioid tapering: a pilot randomised controlled trial

Introduction

Recent changes in opioid prescribing guidelines have led to an increasing number of patients with chronic pain being recommended to taper. However, opioid tapering can be challenging, and many patients require support.

Objectives

We evaluated the feasibility, acceptability, and potential efficacy of a codesigned digital health intervention to support patients with chronic pain during voluntary prescription opioid tapering.

Methods

In a pilot randomised controlled trial, participants received a psychoeducational video and 28 days of text messages (2 SMS/day) in addition to their usual care (intervention) or usual care alone (control). The feasibility, acceptability, and potential efficacy of the intervention were evaluated. The primary outcome was opioid tapering self-efficacy. Secondary outcomes were pain intensity and interference, anxiety and depression symptom severity, pain catastrophising, and pain self-efficacy.

Results

Of 28 randomised participants, 26 completed the study (13 per group). Text message delivery was high (99.2%), but fidelity of video delivery was low (57.1%). Most participants rated the messages as useful, supportive, encouraging, and engaging; 78.5% would recommend the intervention to others; and 64.2% desired a longer intervention period. Tapering self-efficacy (Cohen d = 0.74) and pain self-efficacy (d = 0.41) were higher, and pain intensity (d = 0.65) and affective interference (d = 0.45) were lower in the intervention group at week 4.

Conclusion

First evidence supports the feasibility, acceptability, and potentially efficacy of a psychoeducational video and SMS text messaging intervention to support patients with chronic pain during voluntary prescription opioid tapering. Definitive trials with longer intervention duration are warranted.

Patients' Experiences of Digital Health Interventions for the Self-Management of Chronic Pain: Protocol for a Systematic Review and Thematic Synthesis

BACKGROUND

Chronic pain is a highly prevalent condition that requires multidisciplinary treatment. However, in the United Kingdom, access to specialist pain clinics where patients can receive medical multidisciplinary treatment is limited, and provision varies between health boards. As such, self-management of chronic pain using digital tools has been gaining traction recently, but evidence of its effectiveness from clinical-based trials focuses mainly on quantitative outcomes.

OBJECTIVE

This systematic review aims to identify, appraise, and synthesize qualitative evidence on patients' experiences with digital health interventions (DHIs) for the management of chronic pain.

METHODS

This systematic review will consider qualitative and mixed methods studies that explore the experience of patients (aged 18 years and older) with chronic pain engaging in DHIs to manage their pain. MEDLINE Ovid, PubMed, Embase, CINAHL, PsycINFO, and Scopus databases will be searched for published studies. The systematic review will be conducted in accordance with the ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines. Following the 3-step thematic synthesis methodology of Thomas and Harden, titles and abstracts will be screened by 2 independent reviewers (AM and HM), and a third reviewer (MI or FM) will resolve any conflict that arises before the full-text screening. The Critical Appraisal Skills Programme checklist tool will be used to critically appraise the included studies. The extracted data will be imported to NVivo (QSR International), where thematic synthesis will be used to derive analytical themes from the included studies.

RESULTS

Themes that encapsulate the patient experience will be identified from qualitative evidence, and these themes will shed light on the perceived benefits and disadvantages, usability, acceptability, and the overall impact digital tools can have on the lives of those with chronic pain.

CONCLUSIONS

This systematic review will identify, appraise, and synthesize the overall experience of patients engaging in DHI to manage a diverse range of chronic pain conditions. By elaborating the patient experience through qualitative analysis, the findings from this review will enhance our current understanding of the experiences of patients with chronic pain using digital tools for the self-management of their pain and highlight what person-centered elements are essential for future DHI development.

TRIAL REGISTRATION

PROSPERO CRD42023445100; http://tinyurl.com/4z77khfs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52469.

Musculoskeletal and Neuropathic Pain in COVID-19

Chronic pain constitutes a significant disease burden globally and accounts for a substantial portion of healthcare spending. The COVID-19 pandemic contributed to an increase in this burden as patients presented with musculoskeletal or neuropathic pain after contracting COVID-19 or had their chronic pain symptoms exacerbated by the virus. This extensive literature review analyzes the epidemiology of pain pre-pandemic, the costs associated with the COVID-19 pandemic, the impact of the virus on the body, mechanisms of pain, management of chronic pain post-pandemic, and potential treatment options available for people living with chronic pain who have had or are currently infected with COVID-19.

Acceptability of the power over pain portal among patients awaiting tertiary care consultation: A qualitative study of patients' perceptions

Objective

Chronic pain affects approximately 7.6 million Canadians and access to care remains an issue. The Power Over Pain (POP) Portal offers immediate access to evidence-based resources ranging from low- (e.g. education, self-management), to high- (e.g. individual counseling) intensity. We explored the POP Portal's acceptability, usability, and perceived usefulness among patients newly referred to a tertiary care pain clinic.

Methods

We used a descriptive, qualitative approach with a prospective cohort of 60 adult patients recently referred to The Ottawa Hospital Pain Clinic. Patients were offered an orientation session and asked to participate in a seven-week follow-up interview. Data were thematically analyzed in an iterative process, whereby responses were reviewed and coded by two members of the research team.

Results

Of the 60 patients referred to the POP Portal by clinic clerks, 45 participated in the orientation session, and 40 completed a four-week follow-up. All 40 patients had used the POP Portal and recommended that we continue to offer the POP Portal to patients awaiting care. We identified overarching themes of acceptability (five subthemes), usability (ten subthemes), accessibility (three subthemes), and patient value of the POP Portal (three subthemes). This includes (1) the POP Portal provides easy access to chronic pain resources; (2) the POP Portal is helpful in developing an understanding of chronic pain; and (3) improvements to the POP Portal are needed to increase usability and foster a user-friendly experience.

Conclusions

The POP Portal offers accessible and diverse resources for people living with pain awaiting a tertiary care consultation; however, patients would like to see resources specific to diagnosis. Improvements are suggested to allow greater increase the POP Portal usability.

Effectiveness of occupational therapy-led computer-aided interventions on function among adults with conditions of the hand, wrist, and forearm: A systematic literature review and meta-analysis

Introduction

Upper extremity injuries are common, and often treated by occupational therapists. The need to evaluate the effectiveness of occupational therapy interventions to guide practice is pertinent. This systematic review and meta-analysis investigate the effectiveness of occupational therapy-led computer-aided interventions among adults with conditions of the hand, wrist, and forearm.

Methods

A systematic literature search of five databases was undertaken for randomized studies examining occupational therapy-led computer-aided interventions for the treatment of hand, wrist, and forearm conditions. The primary outcome was function, with secondary outcomes of pain, grip and pinch strength. The quality of the included studies was independently assessed using the Cochrane Risk of Bias V2 tool. Meta-analyses were completed.

Results

Three randomized controlled trials were included with 176 participants. One study reported on app use on a tablet and two studies reported on computer gaming. Participants had a variety of hand and wrist diagnoses, treated both conservatively and operatively. There is limited evidence demonstrating that computer-based interventions are as effective as other occupational therapy-led interventions in improving function, pain, grip and pinch strength post-intervention, including small effect size following meta-analysis: grip strength (Fixed Effects Model, SMD 0.13, 95% CI 2.63; -2.36, I2 = 0%) and pinch strength (Fixed Effects Model, SMD -0.12, 95% CI 1.25; -1.50, I2 = 11%).

Conclusions

Limited evidence was found to support the use of computer-aided interventions for adults with a hand, wrist or forearm injury. Further high-quality research is recommended inclusive of a broader range of technologies and a broader range of clinical and patient-reported outcome measures.

The Web-Based Pain-at-Work Toolkit With Telephone Support for Employees With Chronic or Persistent Pain: Protocol for a Cluster Randomized Feasibility Trial

BACKGROUND

Chronic or persistent pain affects one's ability to work or be productive at work, generating high societal and economic burden. However, the provision of work-related advice and support for people with chronic pain is variable or lacking. The Pain-at-Work (PAW) Toolkit was cocreated with people who live with pain, health care professionals, and employers. It aims to increase knowledge about employee rights and how to access support for managing a painful chronic condition in the workplace and provides advice on lifestyle behaviors that facilitate the management of chronic pain.

OBJECTIVE

We aimed to establish the feasibility of conducting a definitive cluster randomized controlled trial comparing access to the PAW Toolkit and telephone support calls from an occupational therapist (PAW) with treatment as usual (ie, standard support from their employer). Our primary outcomes are establishing parameters of feasibility, acceptability, usability, and safety of this digital workplace health intervention. We will assess the candidate primary and secondary outcomes' feasibility and test research processes for a definitive trial.

METHODS

This is an open-label, parallel 2-arm pragmatic feasibility cluster randomized controlled trial with exploratory health economics analysis and a nested qualitative interview study. We aim to recruit 120 participants from at least 8 workplace clusters (any type, >10 employees) in England. The recruitment of workplaces occurs via personal approach, and the recruitment of individual participants is web based. Eligible participants are vocationally active adults aged ≥18 years with internet access and self-reporting chronic pain interfering with their ability to undertake or enjoy productive work. A restricted 1:1 cluster-level randomization is used to allocate employment settings to PAW or treatment as usual; participants are unblinded to group allocation. Following site- and individual-level consent, participants complete a web-based baseline survey (time 0), including measures of work capacity, health and well-being, and health care resource use. Follow-up is performed at 3 months (time 1) and 6 months (time 2). Feasibility outcomes relate to recruitment; intervention fidelity (eg, delivery, reach, uptake, and engagement); retention; and follow-up. Qualitative evaluation (time 2) is mapped to the Capability, Opportunity, Motivation-Behavior model and will explore intervention acceptability to employees and employers, along with individual and contextual factors influencing the delivery and uptake of the intervention.

RESULTS

Ethics approval was obtained in March 2023. Trial recruitment began in June 2023.

CONCLUSIONS

The PAW Toolkit is the first evidence-based digital health intervention aimed at supporting the self-management of chronic or persistent pain at work. This study will inform the design of a definitive trial, including sample size estimation, approaches to cluster site identification, primary and secondary outcomes' selection, and the final health economic model. Findings will inform approaches for the future delivery of this digital health intervention.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05838677; https://clinicaltrials.gov/study/NCT05838677.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51474.

Text messaging intervention to support patients with chronic pain during prescription opioid tapering: protocol for a double-blind randomised controlled trial

INTRODUCTION

Increases in pain and interference with quality of life is a common concern among people with chronic non-cancer pain (CNCP) who are tapering opioid medications. Research indicates that access to social and psychological support for pain self-management may help people to reduce their opioid dose without increasing pain and interference. This study evaluates the efficacy of a text messaging intervention designed to provide people with CNCP with social and psychological support for pain self-management while tapering long-term opioid therapy (LTOT) under the guidance of their prescriber.

METHODS AND ANALYSIS

A double-blind randomised controlled trial will be conducted. Patients with CNCP (n=74) who are tapering LTOT will be enrolled from across Australia. Participants will continue with their usual care while tapering LTOT under the supervision of their prescribing physician. They will randomly receive either a psychoeducational video and supportive text messaging (two Short Message Service (SMS) per day) for 12 weeks or the video only. The primary outcome is the pain intensity and interference assessed by the Pain, Enjoyment of Life and General Activity scale. Secondary outcomes include mood, self-efficacy, pain cognitions, opioid dose reduction, withdrawal symptoms, and acceptability, feasibility, and safety of the intervention. Participants will complete questionnaires at baseline and then every 4 weeks for 12 weeks and will be interviewed at week 12. This trial will provide evidence for the efficacy of a text messaging intervention to support patients with CNCP who are tapering LTOT. If proven to be efficacious and safe, this low-cost intervention can be implemented at scale.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12622001423707.

Physician perspectives on chronic pain management: barriers and the use of eHealth in the COVID-19 era

BACKGROUND

Chronic pain is a highly prevalent and disabling condition which is often undertreated and poorly managed in the community. The emergence of COVID-19 has further complicated pain care, with an increased prevalence of chronic pain and mental health comorbidities, and burnout among physicians. While the pandemic has led to a dramatic increase in virtual health care visits, the uptake of a broader range of eHealth technologies remains unclear. The present study sought to better understand physicians' current needs and barriers in providing effective pain care within the context of COVID-19, as well as gauge current use, interest, and ongoing barriers to eHealth implementation.

METHODS

A total of 100 practicing physicians in British Columbia, Canada, completed a brief online survey.

RESULTS

The sample was comprised of physicians practicing in rural and urban areas (rural = 48%, urban = 42%; both = 10%), with the majority (72%) working in family practice. The most prominent perceived barriers to providing chronic pain care were a lack of interdisciplinary treatment and allied health care for patients, challenges related to opioid prescribing and management, and a lack of time to manage the complexities of chronic pain. Moreover, despite expressing considerable interest in eHealth for chronic pain management (82%), low adoption rates were observed for several technologies. Specifically, only a small percentage of the sample reported using eHealth for the collection of intake data (21%), patient-reported outcomes (14%), and remote patient monitoring (26%). The most common perceived barriers to implementation were cost, complexity, and unfamiliarity with available options.

CONCLUSIONS

Findings provide insight into physicians' ongoing needs and barriers in providing effective pain management during the COVID-19 pandemic. Despite the potential for eHealth technologies to help address barriers in pain care, and strong interest from physicians, enhanced useability, education and training, and funding are likely required to achieve successful implementation of a broader range of eHealth technologies in the future.

An Observational Study of Outcomes Associated With Virtual Pain Management Programs Based on Acceptance and Commitment Therapy Implemented During the COVID-19 Pandemic

OBJECTIVE

In response to COVID-19, virtual, group-based interdisciplinary pain management programs (PMPs) were rapidly implemented. This included implementing different intensities and formats of virtual PMPs to address a range of patient needs and complexity. This observational study investigated outcomes associated with virtual high and low-intensity and pre-neuromodulation PMPs based on acceptance and commitment therapy as part of routine care during the pandemic.

METHODS

Depending on patients' needs, participants completed a virtual high-intensity or low-intensity PMP, or a virtual PMP in preparation for neuromodulation, from June 2020 to June 2022. Participants completed standardized measures of pain intensity and interference, work and social adjustment, depression, and pain acceptance before and after treatment. Data from 2018 to 2019 for in-person residential ( n= 561), outpatient ( n =123), and pre-neuromodulation ( n =207) PMPs were also examined to provide a historical benchmark of performance.

RESULTS

The virtual high-intensity PMP ( n =294) showed significant improvements in all variables, with small effects. There were significant improvements with small effects for pain interference, depression, and acceptance for the virtual pre-neuromodulation PMP ( n =129). No statistically significant improvements were observed for the virtual low-intensity PMP ( n =90). The improvements associated with prepandemic in-person PMPs were generally larger relative to the virtual PMPs of comparable intensity delivered during the pandemic.

DISCUSSION

These data provide preliminary support for the potential benefits of high, but not low, intensity virtual acceptance and commitment therapy-based PMPs, including in the context of neuromodulation. Research is needed to maximize the impact of virtual PMPs and match patients with the most appropriate delivery format.

"Online, the counselor can't see me cry": a systematic literature review on emotion and computer-mediated care

Introduction

Computer-mediated care is becoming increasingly popular, but little research has been done on it and its effects on emotion-related outcomes. This systematic literature review aims to create an overview that addresses the research question: "Is there a relationship between computer-mediated care and emotional expression, perception, and emotional and (long-term) emotion outcomes?"

Method

This systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used five eligibility criteria, namely, (1) participants: adults seeking support; (2) intervention: eHealth; (3) diagnostic criteria: transdiagnostic concept of difficulty identifying, expressing, and/or regulating emotions (e.g., alexithymia); (4) comparator: either face-to-face care or no comparator; and (5) study design: quantitative studies or qualitative studies. Quality was assessed using the QualSyst tool.

Results

The analysis includes 25 research papers. Self-paced interventions appear to have a positive effect on emotion regulation. Videoconferencing interventions improved emotion regulation from before to after treatment but worsened emotion regulation compared with face-to-face treatment.

Discussion

The lack of variation in the modalities studied and the emotion measurements used make it difficult to draw responsible conclusions. Future research should examine how different modalities affect the real-time communication of emotions and how non-verbal cues influence this.

Mapping the Design Space of Technology-Based Solutions for Better Chronic Pain Care: Introducing the Pain Tech Landscape

OBJECTIVES

Technology has substantial potential to transform and extend care for persons with chronic pain, a burdensome and costly condition. To catalyze the development of impactful applications of technology in this space, we developed the Pain Tech Landscape (PTL) model, which integrates pain care needs with characteristics of technological solutions.

METHODS

Our interdisciplinary group representing experts in pain and human factors research developed PTL through iterative discussions. To demonstrate one potential use of the model, we apply data generated from a narrative review of selected pain and technology journals (2000-2020) in the form of heat map overlays, to reveal where pain tech research attention has focused to date.

RESULTS

The PTL comprises three two-dimensional planes, with pain care needs on each x axis (measurement to management) and technology applications on the y axes according to a) user agency (user- to system-driven), b) usage time frame (temporary to lifelong), and c) collaboration (single-user to collaborative). Heat maps show that existing applications reside primarily in the "user-driven/management" quadrant (e.g., self-care apps). Examples of less developed areas include artificial intelligence and Internet of Things (i.e., Internet-linked household objects), and collaborative/social tools for pain management.

CONCLUSIONS

Collaborative development between the pain and tech fields in early developmental stages using the PTL as a common language could yield impactful solutions for chronic pain management. The PTL could also be used to track developments in the field over time. We encourage periodic reassessment and refinement of the PTL model, which can also be adapted to other chronic conditions.

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation.

OBJECTIVES

To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials.

SELECTION CRITERIA

We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up.

AUTHORS' CONCLUSIONS

Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

e-Health Interventions Targeting Pain-Related Psychological Variables in Fibromyalgia: A Systematic Review

There is growing evidence to support the potential benefit of e-Health interventions targeting psychosocial outcomes and/or pain-related psychological variables for chronic pain conditions, including fibromyalgia syndrome (FMS). This systematic review aims at providing an in-depth description of the available e-Health psychological and/or multicomponent interventions for patients with FMS. Searches were made in PubMed, Cochrane, Web of Science, and PsycINFO up to 15 May 2023, finally including twenty-six articles. The quality of the included articles was medium-high (average quality assessment score of 77.1%). 50% of studies were randomized controlled trials (RCTs) (n = 13), and the majority of them focused exclusively on adult patients with FMS (n = 23) who were predominantly female. Four categories of e-Health modalities were identified: web-based (n = 19), mobile application (m-Health) (n = 3), virtual reality (VR) (n = 2), and video consulting (n = 2). Interventions were mainly based on the cognitive behavioral therapy (CBT) approach (n = 14) and mostly involved contact with a healthcare professional through different digital tools. Overall, a growing number of psychological and multicomponent interventions have been created and delivered using digital tools in the context of FMS, showing their potentiality for improving psychosocial outcomes and pain-related psychological variables. However, some digital tools resulted as underrepresented, and the literature on this topic appears highly heterogeneous precluding robust conclusions.

A Systematic Review and Meta-Analysis of the Effects of Rehabilitation Using Digital Healthcare on Musculoskeletal Pain and Quality of Life

Rehabilitation using digital healthcare (DHC) has the potential to enhance the effectiveness of treatment for musculoskeletal disorders (MSDs) and associated pain by improving patient outcomes, while being cost-effective, safe, and measurable. This systematic review and meta-analysis aimed to evaluate the effectiveness of musculoskeletal rehabilitation using DHC. We searched PubMed, Ovid-Embase, Cochrane Library, and PEDro Physiotherapy Evidence Database from inception to October 28, 2022 for controlled clinical trials comparing DHC to conventional rehabilitation. We used a random-effects model for the meta-analysis, pooling the effects of DHC on pain and quality of life (QoL) by calculating standardized mean differences (SMDs) with 95% confidence intervals (CIs) between DHC rehabilitation and conventional rehabilitation (control). Fifty-four studies with 6240 participants met the inclusion criteria. The sample size ranged from 26 to 461, and the average age of the participants ranged from 21.9 to 71.8 years. The majority of the included studies focused on knee or hip joint MSD (n = 23), and the most frequently utilized DHC interventions were mobile applications (n = 26) and virtual or augmented reality (n = 16). Our meta-analysis of pain (n = 45) revealed that pain reduction was greater in DHC rehabilitation than in conventional rehabilitation (SMD: -0.55, 95% CI: -0.74, -0.36), indicating that rehabilitation using DHC has the potential to ameliorate MSD pain. Furthermore, DHC significantly improved health-related QoL and disease-specific QoL (SMD: 0.66, 95% CI: 0.29, 1.03; SMD: -0.44, 95% CI: -0.87, -0.01) compared to conventional rehabilitation. Our findings suggest that DHC offers a practical and flexible rehabilitation alternative for both patients with MSD and healthcare professionals. Nevertheless, further researches are needed to elucidate the underlying mechanisms by which DHC affects patient-reported outcomes, which may vary depending on the type and design of the DHC intervention.

Implementation of an online pain science education for chronic musculoskeletal pain in Brazilian public health system: protocol for a hybrid type III randomised controlled trial with economic evaluation

BACKGROUND

Although clinical practice guidelines recommend pain education as the first-line option for the management of chronic musculoskeletal pain, there is a lack of pain education programmes in healthcare. Thus, digital health programmes can be an effective tool for implementing pain education strategies for public health. This trial will aim to analyse the implementation and effectiveness outcomes of three online pain science education strategies in the Brazilian public health system (SUS) for individuals with chronic musculoskeletal pain.

METHODS

We will conduct a hybrid type III effectiveness-implementation randomised controlled trial with economic evaluation. We will include adult individuals with chronic musculoskeletal pain, recruited from primary healthcare in the city of Guarapuava, Brazil. Individuals will be randomised to three implementation groups receiving a pain science education intervention (EducaDor) but delivered in different modalities: group 1) synchronous online; group 2) asynchronous videos; and group 3) interactive e-book only. Implementation outcomes will include acceptability, appropriateness, feasibility, adoption, fidelity, penetration, sustainability, and costs. We will also assess effectiveness outcomes, such as pain, function, quality of life, sleep, self-efficacy, and adverse effects. Cost-effectiveness and cost-utility analyses will be conducted from the SUS and societal perspectives. The evaluations will be done at baseline, post-intervention (10 weeks), and 6 months.

DISCUSSION

This study will develop and implement a collaborative intervention model involving primary healthcare professionals, secondary-level healthcare providers, and patients to enhance self-management of chronic pain. In addition to promoting better pain management, this study will also contribute to the field of implementation science in public health by generating important insights and recommendations for future interventions.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05302180; 03/29/2022).

Using Personas in the development of eHealth interventions for chronic pain: A scoping review and narrative synthesis

Objectives

Behavioral eHealth interventions can enhance self-management and improve well-being in people with chronic pain. The development of these interventions calls for a user-centered approach to ensure that patient needs are appreciated. However, it may be challenging to involve patients; particularly during the early stages of the process. Fictional user profiles, known as Personas, can represent needs and guide designing eHealth interventions. This article provides a comprehensive overview of the use of Personas in the development of behavioral eHealth interventions for people with chronic pain with the aim to identify benefits and challenges.

Methods

Bibliographic databases (Medline, Web of Science Core Collection, PsycInfo, CINAHL) and registries (PubMed Central, medaRxiv) were systematically searched. In a double-reviewing process, n = 6830 hits and n = 351 full-texts were screened and read. Ten peer-reviewed studies published between 2017 and 2022 were included in the narrative synthesis.

Findings

Ten studies reported using "Pain Personas" in the development of eHealth interventions for such purposes as to gain a shared understanding of the user and to discuss solutions in team meetings, or for patients to identify with (if Personas are included in the intervention). Personas were based on qualitative and/or quantitative data. However, the procedure for creating Personas was only described in half of the included studies (n = 5). These five studies provided descriptive details of the Personas (i.e., picture, name, narrative of their pain behavior, technological skills, and motivation).

Conclusions

Although Personas have been used by pain researchers in recent projects and were highlighted as an important ingredient in the development process, available design guidelines for the creation and use of Personas are not followed or communicated transparently. Benefits and challenges when using Personas in the development of eHealth interventions for people with chronic pain are discussed to support future eHealth efforts and to improve the quality of eHealth innovation in the field of pain.

Pain Management in the Post-COVID Era-An Update: A Narrative Review

An extensive computer search (from January 2020 to January 2023) was conducted including literature from the PubMed, Scopus, MEDLINE, Web of Science, and EMBASE databases. According to preset criteria, a total of 58 articles were included in this review article. Generally, any patient who becomes infected with COVID-19 can develop post-COVID-19 conditions. The course of COVID-19 is divided into three main stages: acute COVID-19 (up to 4 weeks), post-acute COVID-19 (from 4 to 12 weeks), and post-COVID (from 12 weeks to 6 months). If a more protracted course of COVID (over 6 months) is demonstrated, the term "long-COVID" is used. Although the acute stage of COVID-19 infection most commonly manifests with acute respiratory symptoms, one very common symptom of the disease is pain, while the most common symptoms of post-COVID syndrome are shortness of breath, dry cough, fatigue, loss of olfactory and gustatory function, tightness and chest pain, sleep and mood disturbances, body aches, muscle and joint pain, sore throat, fever, and persistent headaches. All observations demonstrated a high incidence of chronic pain syndromes of various localization in the post- and long-COVID period. Post-COVID chronic pain might include a newly developed chronic pain as a part of post-viral syndrome; worsening of preexisting chronic pain due to the associated changes in the medical services, or a de novo chronic pain in healthy individuals who are not infected with COVID. Chronic pain during and post-COVID-19 pandemic is an important health issue due to the significant impacts of pain on the patients, health care systems, and society as well. Therefore, it is important that patients with chronic pain receive effective treatment according to their specific needs. Accordingly, the main goal of this review article is to provide a broad description about the post-COVID pain and to explore the impact of long COVID-19 on chronic pain patients, and also to give brief reports about the prevalence, risk factors, possible mechanisms, different presentations, and the management tools through a systematic approach.

Pre-implementation formative evaluation of cooperative pain education and self-management expanding treatment for real-world access: A pragmatic pain trial

OBJECTIVE

Cognitive behavioral therapy for chronic pain (CBT-CP) is an evidence-based treatment for improving functioning and pain intensity for people with chronic pain with extensive evidence of effectiveness. However, there has been relatively little investigation of the factors associated with successful implementation and uptake of CBT-CP, particularly clinician and system level factors. This formative evaluation examined barriers and facilitators to the successful implementation and uptake of CBT-CP from the perspective of CBT-CP clinicians and referring primary care clinicians.

METHODS

Qualitative interviews guided by the Consolidated Framework for Implementation Research were conducted at nine geographically diverse Veterans Affairs sites as part of a pragmatic clinical trial comparing synchronous, clinician-delivered CBT-CP and remotely delivered, technology-assisted CBT-CP. Analysis was informed by a grounded theory approach.

RESULTS

Twenty-six clinicians (CBT-CP clinicians = 17, primary care clinicians = 9) from nine VA medical centers participated in individual qualitative interviews conducted by telephone from April 2019 to August 2020. Four themes emerged in the qualitative interviews: (1) the complexity and variability of referral pathways across sites, (2) referring clinician's lack of knowledge about CBT-CP, (3) referring clinician's difficulty identifying suitable candidates for CBT-CP, and (4) preference for interventions that can be completed from home.

CONCLUSIONS

This formative evaluation identified clinician and system barriers to widespread implementation of CBT-CP and allowed for refinement of the subsequent implementation of two forms of CBT-CP in an ongoing pragmatic trial. Identification of relative difference in barriers and facilitators in the two forms of CBT-CP may emerge more clearly in a pragmatic trial that evaluates how treatments perform in real-world settings and may provide important information to guide future system-wide implementation efforts.

A Systematic Review of the Adherence to Home-Practice Meditation Exercises in Patients with Chronic Pain

Mindfulness-, compassion-, and acceptance-based (i.e., "third wave") psychotherapies are effective for treating chronic pain conditions. Many of these programs require that patients engage in the systematic home practice of meditation experiences so they can develop meditation skills. This systematic review aimed at evaluating the frequency, duration, and effects of home practice in patients with chronic pain undergoing a "third wave" psychotherapy. A comprehensive database search for quantitative studies was conducted in PubMed, Embase, and Web of Sciences Core Collection; 31 studies fulfilled the inclusion criteria. The reviewed studies tended to indicate a pattern of moderately frequent practice (around four days/week), with very high variability in terms of time invested; most studies observed significant associations between the amount of practice and positive health outcomes. Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy were the most common interventions and presented low levels of adherence to home practice (39.6% of the recommended time). Some studies were conducted on samples of adolescents, who practiced very few minutes, and a few tested eHealth interventions with heterogeneous adherence levels. In conclusion, some adaptations may be required so that patients with chronic pain can engage more easily and, thus, effectively in home meditation practices.

Healthcare Access and Delivery During the COVID-19 Pandemic for Black Veterans with Chronic Pain: a Qualitative Study

BACKGROUND

The COVID-19 pandemic led to significant disruptions in healthcare and rapid increases in virtual healthcare delivery. The full effects of these shifts remain unknown. Understanding effects of these disruptions is particularly relevant for patients with chronic pain, which typically requires consistent engagement in treatment to maximize benefit, and for Black patients, given documented racial disparities in pain treatment and telehealth delivery.

OBJECTIVE

To understand how Black patients with chronic pain experienced pandemic-related changes in healthcare delivery.

DESIGN

In-depth, semi-structured qualitative interviews PARTICIPANTS: Black veterans with chronic pain.

KEY RESULTS

Participants described decreased ability to self-manage their chronic pain, obtain nonpharmacological services such as physical therapy, see their primary care providers, and schedule surgery. Most did not believe telehealth met their needs, describing feeling inadequately assessed for their pain and noting that beyond renewing prescriptions, telehealth visits were not that useful. Some believed their communication with their providers suffered from a lack of in-person contact. Others, however, were willing to accept this tradeoff to prevent possible exposure to COVID-19, and some appreciated the convenience of being able to access healthcare from home.

CONCLUSIONS

Black patients with chronic pain described mostly negative effects from the shift to telecare after the pandemic's onset. Given existing disparities and likely persistence of virtual care, research on the longer-term effects of virtual pain care for Black patients is needed.

Characterizing modifications to a comparative effectiveness research study: the OPTIMIZE trial-using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME)

BACKGROUND

The OPTIMIZE trial is a multi-site, comparative effectiveness research (CER) study that uses a Sequential Multiple Assessment Randomized Trial (SMART) designed to examine the effectiveness of complex health interventions (cognitive behavioral therapy, physical therapy, and mindfulness) for adults with chronic low back pain. Modifications are anticipated when implementing complex interventions in CER. Disruptions due to COVID have created unanticipated challenges also requiring modifications. Recent methodologic standards for CER studies emphasize that fully characterizing modifications made is necessary to interpret and implement trial results. The purpose of this paper is to outline the modifications made to the OPTIMIZE trial using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) to characterize modifications to the OPTIMIZE trial in response to the COVID pandemic and other challenges encountered.

METHODS

The FRAME outlines a strategy to identify and report modifications to evidence-based interventions or implementation strategies, whether planned or unplanned. We use the FRAME to characterize the process used to modify the aspects of the OPTIMIZE trial. Modifications were made to improve lower-than-anticipated rates of treatment initiation and COVID-related restrictions. Contextual modifications were made to permit telehealth delivery of treatments originally designed for in-person delivery. Training modifications were made with study personnel to provide more detailed information to potential participants, use motivational interviewing communication techniques to clarify potential participants' motivation and possible barriers to initiating treatment, and provide greater assistance with scheduling of assigned treatments.

RESULTS

Modifications were developed with input from the trial's patient and stakeholder advisory panels. The goals of the modifications were to improve trial feasibility without compromising the interventions' core functions. Modifications were approved by the study funder and the trial steering committee.

CONCLUSIONS

Full and transparent reporting of modifications to clinical trials, whether planned or unplanned, is critical for interpreting the trial's eventual results and considering future implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03859713. Registered on March 1, 2019.

The effects of a mobile app-delivered intervention in people with symptomatic hand osteoarthritis: a pragmatic randomized controlled trial

BACKGROUND

Exercise therapy, self-management and education are recommended interventions for hand osteoarthritis (OA), but new delivery systems are needed to solve lack of adherence.

AIM

To determine the effects on hand function and pain related measures of a mobile app-delivered intervention, compared with usual care, in patients with symptomatic hand OA.

DESIGN

A pragmatic, multicenter, two-group parallel randomized controlled trial.

SETTING

Community health centers in rural southern Spain.

POPULATION

Eighty-three participants with unilateral or bilateral symptomatic hand OA were proposed to participate, and finally 74 were included and randomized.

METHODS

Participants received a home multimodal treatment (exercise, education, and self-management recommendations) with the CareHand mobile app or usual care (written exercises) over 12 weeks. Monthly telephone calls were performed to monitor adherence. The primary outcome was hand physical function (Australian/Canadian Hand Osteoarthritis Index, AUSCAN) at 3- and 6-months. Secondary measures included hand pain intensity and morning stiffness, upper limb function, hand dexterity, and grip and pinch strength.

RESULTS

The CareHand group showed significant within-group changes in hand function at 6-months (-3.0, 95% CI -5.1 to -0.9 vs. usual care: -0.9, 95% CI -3.3 to 1.5). Neither group showed improvements in hand function at 3-months (CareHand: -1.5, 95% CI -3.1 to 0.1; usual care: -0.5, 95% CI -2.7 to 1.7). For the secondary outcomes, the CareHand group showed better results on upper limb function both at 3- and 6-months, and on pain both at 1- and 3-months compared to usual care group. Linear regression models indicated that baseline scores of pain intensity, hand status, and upper limb function were associated with a greater improvement in hand pain and physical function.

CONCLUSIONS

A mobile app-delivered intervention is effective for improving hand function, and better than usual care for upper limb function and pain. Further research is warranted to understand the impact of mobile health (mHealth) in people with hand OA.

CLINICAL REHABILITATION IMPACT

mHealth interventions are a feasible and secure multimodal delivery approach in older adults with hand OA in rural primary care setting. Baseline pain and upper limb function might predict functional hand outcomes.

Telerehabilitation for musculoskeletal pain - An overview of systematic reviews

Background

Alternative measures for minimizing musculoskeletal pain, such as telerehabilitation, can be implemented in the context of the COVID-19 pandemic.

Objective

The aim of the present overview was to examine evidence from systematic reviews of telerehabilitation for managing musculoskeletal pain.

Methods

This study was conducted following the PRISMA recommendations. Searches were conducted of the Pubmed/Medline, Scopus, Cochrane Library, Web of Science and Embase databases for review articles published from the inception of the database to July 2022. To be included, the studies needed to be a systematic review, include any type of telerehabilitation and present any outcome related to musculoskeletal pain. Studies not available in English were excluded. Theses, dissertations, letters, conference abstracts and narrative reviews were also excluded. The methodological quality of the reviews was appraised using the Assessing the Methodological Quality of Systematic Reviews criteria. Data extraction was performed by two reviewers and included the characterization of the clinical condition and telerehabilitation program, main outcomes, method for appraising the methodological quality of the primary studies, results and quality of evidence.

Results

The search led to the retrieval of 390 potentially eligible studies and 16 systematic reviews were included in this overview. Eleven reviews had meta-analyses and most had high methodological quality. Five of six systematic reviews reported evidence supporting the telehealth intervention for chronic pain conditions; and two of three high-quality systematic reviews reported the absence of evidence for non-specific low back pain.

Conclusions

This overview of systematic reviews enables a better understanding of the characteristics of telerehabilitation programs, provides information for use in clinical practice and describes gaps in the research that need to be filled.

The effectiveness of eHealth interventions on female pelvic floor dysfunction: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

eHealth interventions represent a promising novel strategy in pelvic floor management for women. Nevertheless, the effectiveness of eHealth interventions among women with or at risk of pelvic floor dysfunction (PFD) has not been adequately discussed to date. This study aimed to determine the effectiveness of eHealth interventions in preventing and treating PFD among women.

METHODS

Eleven electronic databases were searched for randomized controlled trials (RCTs) from inception until August 28, 2021.

RESULTS

Twenty-four RCTs were included in this meta-analysis that included 3691 women. The meta-analysis showed that eHealth interventions were not only vital for preventing PFD (pregnant women: pooled OR = 0.25, 95% CI: 0.14 to 0.45, p < 0.001; postnatal women: pooled OR = 0.19, 95% CI: 0.06 to 0.60, p = 0.005), but also for reducing the severity of PFD (pooled SMD = -0.63, 95% CI: -1.20 to -0.06, p = 0.031). In addition, compared with traditional care, eHealth interventions showed significant positive effects on several outcome indicators, including quality of life (pooled SMD = 0.49, 95% CI: 0.19 to 0.80, p = 0.002), pelvic floor type I muscle strength (pooled OR = 1.92, 95% CI: 1.30 to 2.82, p = 0.001), pelvic floor type II muscle strength (pooled OR = 2.04, 95% CI: 1.38 to 3.01, p < 0.001), sexual function (pooled SMD = 0.51, 95% CI: 0.29 to 0.73, p < 0.001), satisfaction (pooled OR = 3.93, 95% CI: 2.73 to 5.66, p < 0.001), and self-efficacy (pooled SMD = 2.62, 95% CI: 2.12 to 3.13, p < 0.001).

CONCLUSIONS

eHealth interventions are an effective emerging treatment and preventive modality for female PFD. Higher quality, larger scale, and strictly designed RCTs are warranted to evaluate the effectiveness of eHealth interventions on female pelvic floor management.

"Back Rx, a personalized mobile phone application for discogenic chronic low back pain: a prospective pilot study"

Background

Intervertebral disc pathology is the most common identifiable cause of chronic lower back pain (CLBP). There are limited conservative alternatives to treat discogenic axial CLBP. Back Rx is a mobile application (app) developed to treat patients with this condition, following the Back Rx exercise program, assisted by a virtual coach.

Methods

Patients 18 to 65 years of age, with axial CLBP (more than 3 months), and evidence of lumbar disc pathology by magnetic resonance imaging (MRI) were enrolled to the study. Patients’ symptomatology was prospectively evaluated at baseline and after 3 months of using the Back Rx app. The main outcome of the study was back pain evaluated using the visual analog scale (VAS) for pain. Secondary outcomes were the patient's functionality, the weekly pain medication intake, the patients’ adherence to the app, and the patients´ satisfaction rate.

Results

Seventy-five patients with CLBP were enrolled in the study. All patients had a statistically significant improvement from baseline to final follow-up in the average VAS scores, and the functionality evaluations. Average VAS scores decreased from 5.17 ± 2.1 at baseline to 3.8 ± 2.6 at final follow-up (P = 0.016). Patients showed a significant decrease in the number of pain medications taken during a week (P = 0.001). Overall compliance with the app was 52%, and 65% of the patients rated the overall experience as good or excellent.

Conclusion

The Back Rx app decreased pain and increased function in patients with discogenic axial CLBP compared to their baseline status. Further measures are needed to increase patients' compliance with the app and the Back Rx program.

Trial registration

Retrospectively registered in 2/2/2017 NCT03040310 (ClinicalTrials.gov).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05883-9.

Agile development of a digital exposure treatment for youth with chronic musculoskeletal pain: protocol of a user-centred design approach and examination of feasibility and preliminary efficacy

INTRODUCTION

Chronic pain affects a significant number of children and impacts multiple domains including social, emotional and behavioural functioning, and negatively impacts family functioning. Roughly 5% of youth with chronic pain experience moderate to severe pain-related disability, with pain-related fear and avoidance of activities being identified as substantial barriers to treatment engagement. Evidence supports targeted psychological and physical interventions to address these barriers (eg, graded-exposure treatment), but accessibility to intervention is undermined by a shortage of services outside of urban areas, high treatment-related costs, and long provider waitlists; highlighting the need to develop digitally delivered behavioural intervention, using agile and iterative study designs that support rapid development and timely dissemination.

METHODS AND ANALYSIS

This study seeks to develop an effective and scalable intervention for youth with chronic pain and their caregivers. This paper presents a user-centred protocol for the development and refinement of a digital exposure treatment for youth and caregivers, as well as the study design to examine feasibility and preliminary efficacy of the treatment using single-case experimental design (SCED). Assessments include daily diaries, completed from baseline and daily throughout the intervention (~6 weeks), and at 3-month follow-up, as well as self-report measures completed at baseline, end of intervention and 3-month follow-up. Primary outcomes include treatment satisfaction, treatment expectancy, adherence to daily dairies and functional disability. Secondary outcomes are pain-related fear and avoidance of activities, pain catastrophising and pain acceptance. We will present descriptive and model-based inference analyses, based on SCED reporting guidelines. We will calculate effect sizes for each individual on each outcome. We will examine mean treatment expectancy, credibility and satisfaction scores, and patient drop-out percentage.

ETHICS AND DISSEMINATION

This study is approved by the Institutional Review Board at Stanford University (protocol #53323). Findings will be actively disseminated through peer-reviewed journals, conference presentations and social media.

TRIAL REGISTRATION NUMBER

NCT05079984.

Consumers’ Willingness to Pay for eHealth and Its Influencing Factors: Systematic Review and Meta-analysis

Background

Despite the great potential of eHealth, substantial costs are involved in its implementation, and it is essential to know whether these costs can be justified by its benefits. Such needs have led to an increased interest in measuring the benefits of eHealth, especially using the willingness to pay (WTP) metric as an accurate proxy for consumers’ perceived benefits of eHealth. This offered us an opportunity to systematically review and synthesize evidence from the literature to better understand WTP for eHealth and its influencing factors.

Objective

This study aimed to provide a systematic review of WTP for eHealth and its influencing factors.

Methods

This study was performed and reported as per the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, CINAHL Plus, Cochrane Library, EconLit, and PsycINFO databases were searched from their inception to April 19, 2022. We conducted random-effects meta-analyses to calculate WTP values for eHealth (at 2021 US dollar rates) and meta-regression analyses to examine the factors affecting WTP.

Results

A total of 30 articles representing 35 studies were included in the review. We found that WTP for eHealth varied across studies; when expressed as a 1-time payment, it ranged from US $0.88 to US $191.84, and when expressed as a monthly payment, it ranged from US $5.25 to US $45.64. Meta-regression analyses showed that WTP for eHealth was negatively associated with the percentages of women (β=−.76; P<.001) and positively associated with the percentages of college-educated respondents (β=.63; P<.001) and a country’s gross domestic product per capita (multiples of US $1000; β=.03; P<.001). Compared with eHealth provided through websites, people reported a lower WTP for eHealth provided through asynchronous communication (β=−1.43; P<.001) and a higher WTP for eHealth provided through medical devices (β=.66; P<.001), health apps (β=.25; P=.01), and synchronous communication (β=.58; P<.001). As for the methods used to measure WTP, single-bounded dichotomous choice (β=2.13; P<.001), double-bounded dichotomous choice (β=2.20; P<.001), and payment scale (β=1.11; P<.001) were shown to obtain higher WTP values than the open-ended format. Compared with ex ante evaluations, ex post evaluations were shown to obtain lower WTP values (β=−.37; P<.001).

Conclusions

WTP for eHealth varied significantly depending on the study population, modality used to provide eHealth, and methods used to measure it. WTP for eHealth was lower among certain population segments, suggesting that these segments may be at a disadvantage in terms of accessing and benefiting from eHealth. We also identified the modalities of eHealth that were highly valued by consumers and offered suggestions for the design of eHealth interventions. In addition, we found that different methods of measuring WTP led to significantly different WTP estimates, highlighting the need to undertake further methodological explorations of approaches to elicit WTP values.

Digital Health Interventions for Musculoskeletal Pain Conditions: Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Digital health solutions can provide populations with musculoskeletal pain with high-reach, low-cost, easily accessible, and scalable patient education and self-management interventions that meet the time and resource restrictions.

Objective

The main objective of this study was to determine the effectiveness of digital health interventions for people with musculoskeletal pain conditions (ie, low back pain, neck pain, shoulder pain, knee pain, elbow pain, ankle pain, and whiplash).

Methods

A systematic review and meta-analysis was conducted. We searched PubMed and Cochrane Central Register of Controlled Trials (from 1974 to August 2021) and selected randomized controlled trials of digital health interventions in the target population of patients with musculoskeletal pain with a minimum follow-up of 1 month. A total of 2 researchers independently screened and extracted the data.

Results

A total of 56 eligible studies were included covering 9359 participants, with a mean follow-up of 25 (SD 15.48) weeks. In moderate-quality evidence, digital health interventions had a small effect on pain (standardized mean difference [SMD] 0.19, 95% CI 0.06-0.32), disability (SMD 0.14, 95% CI 0.03-0.25), quality of life (SMD 0.22, 95% CI 0.07-0.36), emotional functioning (SMD 0.24, 95% CI 0.12-0.35), and self-management (SMD 0.14, 95% CI 0.05-0.24).

Conclusions

Moderate-quality evidence supports the conclusion that digital health interventions are effective in reducing pain and improving functioning and self-management of musculoskeletal pain conditions. Low-quality evidence indicates that digital health interventions can improve the quality of life and global treatment. Little research has been conducted on the influence of digital health on expenses, knowledge, overall improvement, range of motion, muscle strength, and implementation fidelity.

Trial Registration

PROSPERO CRD42022307504; https://tinyurl.com/2cd25hus

Development of a responsive website to promote behavior changes in computer users

ABSTRACT The increase in the use of technology for prolonged periods, both inside and outside of work, is associated with a sedentary lifestyle, a risk factor for several health problems. Change in this behavior can be promoted with the use of technologies. We aim to develop an interactive responsive website to promote behavioral changes in computer users. From a literature review, modifiable risk factors associated with health problems in computer users were identified. Messages were created to increase knowledge and promote behavioral changes in users. These messages include recommendations regarding breaks, adjustments in the workplace, physical exercise, hydration, among others. The messages are personalized, and the user includes personal information and current lifestyle habits. All this information was implemented in an interactive responsive website developed in JavaScript language and Node.js engine. The responsive website was developed, including the proposed features, and is available online. Future studies can evaluate the effectiveness of the responsive website in promoting behavioral changes among computer users, improving their health and quality of life.

Desenvolvimento de um site responsivo para promover mudanças comportamentais em usuários de computador

RESUMO O crescimento do uso da tecnologia fez com que os trabalhadores passassem a usar o computador por longos períodos, dentro e fora do trabalho. O uso prolongado de computadores está associado a um estilo de vida sedentário, sendo um fator de risco para diversos problemas de saúde. Porém, a transformação deste comportamento pode ser promovida por meio de tecnologias, como um site responsivo interativo que visa promover mudanças comportamentais em usuários de computador. A partir de um levantamento bibliográfico, foram identificados fatores de risco modificáveis associados aos problemas de saúde nessa população. Em seguida, foram criadas mensagens para ampliar o conhecimento e promover mudanças comportamentais nos usuários. Essas mensagens incluem recomendações a respeito de pausas, ajustes no posto de trabalho, exercícios físicos, hidratação, dentre outras. As mensagens podem ser personalizadas, bastando que, para isso, o usuário inclua informações pessoais e hábitos de vida atuais. Todas as informações foram implementadas em um site responsivo interativo desenvolvido em linguagem JavaScript e motor Node.js. O site responsivo foi desenvolvido, incluindo as funcionalidades propostas, e está disponível online. Em estudos futuros, poderá ser testada a efetividade do site para promover mudanças comportamentais nos usuários de computador, melhorando sua saúde e qualidade de vida.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear-avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear-avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Multimodal Chronic Pain Therapy for Adults via Smartphone: Randomized Controlled Clinical Trial

BACKGROUND

Combination therapies delivered remotely via the internet or mobile devices are increasingly being used to improve and promote the self-management of chronic conditions. However, little is known regarding the long-term effects of these interventions.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a multimodal intervention program that measures associated variables such as catastrophizing, pain acceptance, and quality of life using a mobile device in people with chronic pain in an outpatient setting.

METHODS

A randomized controlled clinical trial was performed using parallel treatment groups. A total of 209 patients with chronic musculoskeletal pain were randomly assigned to one of the two study arms. The intervention group received a standard web-based psychosocial therapy-type program of activities through a smartphone for 6 weeks. The control group only had access to the Find out more section of the app, which contained audiovisual material for pain management based on a self-help approach. The primary outcome was catastrophizing measured using the Pain Catastrophizing Scale (PCS). Secondary outcomes were pain acceptance measured using the Chronic Pain Acceptance Questionnaire and health-related quality of life measured using the EuroQol Visual Analogue Scale. Assessments were conducted at baseline (T1), after treatment (T2), and at the 3-month follow-up (T3). The variations between the different phases were assessed using the percentage change rescaled with log base 2. The Cohen d was calculated based on the results of the linear mixed model. The investigators of the study who evaluated the results were not involved in patient recruitment and were blinded to the group assignment.

RESULTS

Positive effects were found in the intervention group (T2-T1) in catastrophizing between the baseline and posttreatment phases (P<.001) and in helplessness (-0.72 vs 0.1; P=.002), rumination (-1.59 vs -0.53; P<.001), acceptance (0.38 vs 0.05; P=.001), and quality of life (0.43 vs -0.01; P=.002), although no significant changes were found for magnification (0.2 vs 0.77; P=.14) and satisfaction with health (0.25 vs -0.27; P=.13). Three months after treatment, significant differences were observed in the intervention group for the outcome variable of catastrophizing (PCS; -0.59 vs 0.2; P=.006) and the PCS subscales of helplessness (-0.65 vs 0.01; P=.07), rumination (1.23 vs -0.59; P=.04), and magnification (0.1 vs 0.86; P=.02).

CONCLUSIONS

The results of our study suggest that app-based mobile multidimensional treatments for adults with chronic pain improve catastrophizing, quality of life, and psychological flexibility immediately after treatment and that the effects are maintained for the primary outcome of catastrophizing for at least 3 months following treatment. Moreover, they promote self-management and can be used to complement face-to-face pain treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04509154; https://clinicaltrials.gov/ct2/show/NCT04509154.

Evaluating acceptability and feasibility of a mobile health intervention to improve self-efficacy in prescription opioid tapering in patients with chronic pain: protocol for a pilot randomised, single-blind, controlled trial

INTRODUCTION

Opioid medications are no longer recommended as long-term therapy for chronic non-cancer pain, and many patients are advised to reduce or discontinue opioid medications. Many patients report difficulties in tapering opioid medications, necessitating supporting interventions. This protocol describes a pilot randomised controlled trial (RCT) to investigate the acceptability, feasibility and potential efficacy of a mobile health intervention to improve the opioid tapering self-efficacy of patients with chronic non-cancer pain.

METHODS AND ANALYSIS

The trial will be a single-blind (clinician, data collector and statistician-blinded) pilot RCT with two parallel arms. Forty adult patients with chronic non-cancer pain who are voluntarily reducing their prescribed opioid medications under medical guidance will be recruited from two tertiary pain clinics (Start date 25 August 2021). Participants will be randomly assigned to an intervention or control group. Both groups will receive usual care, including multidisciplinary pain management. In addition to usual care, the intervention group will receive a short informational and testimonial video about opioid tapering and will receive two specifically text messages per day for 28 days. The intervention is codesigned with patients and clinicians to provide evidence-based informational, motivational and emotional support to patients with chronic pain to taper opioid medications. Feasibility of the intervention and a future definitive RCT will be evaluated by measuring patient acceptability, delivery of the intervention, rates and reasons of exclusions and drop-outs, completion rates and missing data in the study questionnaires, and obtaining estimates for sample size determination. Potential efficacy will be evaluated by comparing changes in opioid tapering self-efficacy between the two groups.

ETHICS AND DISSEMINATION

The study protocol was reviewed and approved by the Northern Sydney Local Health District (Australia). Study results will be published in peer-reviewed journals and presented at scientific and professional meetings.

TRIAL REGISTRATION NUMBER

ACTRN12621000795897.

Evidence-based digital support during 1 year after an Interdisciplinary Pain Rehabilitation Programme for persons with chronic musculoskeletal pain to facilitate a sustainable return to work: a study protocol for a registry-based multicentre randomised controlled trial

INTRODUCTION

Chronic musculoskeletal pain (CMSP) severely affects the individual's quality of life, functioning and ability to work, and comes with significant societal costs for sick leave and productivity loss. After rehabilitation, patients with CMSP often experience lack of support when responsibility for the return-to-work process is taken over by the employer. Therefore, we aim to evaluate the effectiveness of a digital support (Sustainable WorkEr digital support for Persons with chronic Pain and their Employers (SWEPPE)) for promoting a sustainable return-to-work for persons with CMSP and to facilitate the employers' supportive role and responsibilities in the process.

METHODS AND ANALYSIS

In this registry-based multicentre randomised controlled trial, 360 patients with CMSP will be randomised to either receive the smartphone application SWEPPE (n=180) or to a control group (n=180). The intervention group will use SWEPPE for 1 year and the control group will not receive any intervention for return to work (RTW). Participants will be recruited from approximately 10 specialist and primary care level units connected to the Swedish National Quality Registry for Pain Rehabilitation providing Interdisciplinary Pain Rehabilitation Programmes (IPRP) for CMSP. Eligibility criteria are age 18-65 years and a need for support in RTW or continued support at work for creating a sustainable work situation. Baseline data will be collected when the participants have completed the IPRP. Final assessment will be performed after 12 months. The primary outcome will be a number of days with sickness cash benefit. Secondary outcomes and explanatory variables including important domains affected by CMSP such as health-related quality of life, functioning and work ability will be collected.

ETHICS AND DISSEMINATION

The Swedish Ethics Review Board approved the study (Dnr 2020-01593, Dnr 2021-01854). The study findings will be disseminated through publication, national and international conferences, and meetings to be available for patients, healthcare providers or stakeholders.

TRIAL REGISTRATION NUMBER

NCT05058547.

Development, evaluation and implementation of a digital behavioural health treatment for chronic pain: study protocol of the multiphase DAHLIA project

INTRODUCTION

Chronic pain affects about 20%-40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most people with chronic pain cannot easily access evidence-based behavioural interventions. The overall aim of the DAHLIA project is to develop, evaluate and implement a widely accessible digital behavioural health treatment to improve well-being in individuals with chronic pain.

METHODS AND ANALYSIS

The project follows the four phases of the mHealth Agile Development and Evaluation Lifecycle: (1) development and pre-implementation surveillance using focus groups, stakeholder interviews and a business model; (2) iterative optimisation studies applying single case experimental design (SCED) method in 4-6 iterations with n=10 patients and their healthcare professionals per iteration; (3) a two-armed clinical randomised controlled trial enhanced with SCED (n=180 patients per arm) and (4) interview-based post-market surveillance. Data analyses include multilevel modelling, cost-utility and indicative analyses.In October 2021, inter-sectorial partners are engaged and funding is secured for four years. The treatment content is compiled and the first treatment prototype is in preparation. Clinical sites in three Swedish regions are informed and recruitment for phase 1 will start in autumn 2021. To facilitate long-term impact and accessibility, the treatment will be integrated into a Swedish health platform (www.1177.se), which is used on a national level as a hub for advice, information, guidance and e-services for health and healthcare.

ETHICS AND DISSEMINATION

The study plan has been reviewed and approved by Swedish ethical review authorities. Findings will be actively disseminated through peer-reviewed journals, conference presentations, social media and outreach activities for the wider public.

TRIAL REGISTRATION NUMBER

NCT05066087.

An Exercise and Educational and Self-management Program Delivered With a Smartphone App (CareHand) in Adults With Rheumatoid Arthritis of the Hands: Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a prevalent autoimmune disease that usually involves problems of the hand or wrist. Current evidence recommends a multimodal therapy including exercise, self-management, and educational strategies. To date, the efficacy of this approach, as delivered using a smartphone app, has been scarcely investigated.

OBJECTIVE

This study aims to assess the short- and medium-term efficacy of a digital app (CareHand) that includes a tailored home exercise program, together with educational and self-management recommendations, compared with usual care, for people with RA of the hands.

METHODS

A single-blinded randomized controlled trial was conducted between March 2020 and February 2021, including 36 participants with RA of the hands (women: 22/36, 61%) from 2 community health care centers. Participants were allocated to use the CareHand app, consisting of tailored exercise programs, and self-management and monitoring tools or to a control group that received a written home exercise routine and recommendations, as per the usual protocol provided at primary care settings. Both interventions lasted for 3 months (4 times a week). The primary outcome was hand function, assessed using the Michigan Hand Outcome Questionnaire (MHQ). Secondary measures included pain and stiffness intensity (visual analog scale), grip strength (dynamometer), pinch strength (pinch gauge), and upper limb function (shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire). All measures were collected at baseline and at a 3-month follow-up. Furthermore, the MHQ and self-reported stiffness were assessed 6 months after baseline, whereas pain intensity and scores on the shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at the 1-, 3-, and 6-month follow-ups.

RESULTS

In total, 30 individuals, corresponding to 58 hands (CareHand group: 26/58, 45%; control group: 32/58, 55%), were included in the analysis; 53% (19/36) of the participants received disease-modifying antirheumatic drug treatment. The ANOVA demonstrated a significant time×group effect for the total score of the MHQ (F_1.62,85.67=9.163; P<.001; η²=0.15) and for several of its subscales: overall hand function, work performance, pain, and satisfaction (all P<.05), with mean differences between groups for the total score of 16.86 points (95% CI 8.70-25.03) at 3 months and 17.21 points (95% CI 4.78-29.63) at 6 months. No time×group interaction was observed for the secondary measures (all P>.05).

CONCLUSIONS

Adults with RA of the hands who used the CareHand app reported better results in the short and medium term for overall hand function, work performance, pain, and satisfaction, compared with usual care. The findings of this study suggest that the CareHand app is a promising tool for delivering exercise therapy and self-management recommendations to this population. Results must be interpreted with caution because of the lack of efficacy of the secondary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04263974; https://clinicaltrials.gov/ct2/show/NCT04263974.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04713-4.

eHealth Interventions to Support Self-Management in People With Musculoskeletal Disorders, "eHealth: It's TIME"-A Scoping Review

OBJECTIVE

eHealth-mediated interventions have been proposed as one option to support self-management in those with musculoskeletal disorders (MSDs). This scoping review aimed to chart the evidence regarding eHealth modalities, musculoskeletal diagnosis, and outcomes of eHealth-mediated self-management support interventions in persons with MSDs and identify any gaps within the literature.

METHODS

Six electronic databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus, and the Cochrane Database of Systematic Reviews), 7 grey literature sources (eg, OpenGrey), and reference and citation lists of included studies were searched from database inception to July 2020. Published studies of adult participants with a MSD utilizing an eHealth intervention to support self-management were included. Studies were limited to those published in English. Two reviewers independently screened all studies. Data were extracted by 1 reviewer and reviewed by another reviewer.

RESULTS

After screening 3377 titles and abstracts followed by 176 full texts, 87 studies fulfilled the eligibility criteria. The majority were published in the last 5 years (n = 48; 55%), with almost one-third originating in the United States (n = 28; 32%). The most common eHealth modality type was internet based (n = 22; 35%), with almost one-half (n = 41; 47%) of the included studies involving participants with widespread musculoskeletal symptoms. The most commonly reported outcomes were related to body functions (ie, pain intensity) (n = 67; 45%), closely followed by activities and participation (ie, function) (n = 65; 44%), with environmental factors (ie, health care utilization) the least commonly reported (n = 17; 20%).

CONCLUSIONS

There is considerable variation within the eHealth-mediated self-management support intervention literature. Research is needed on the role of eHealth-mediated self-management support interventions across a broad range of MSDs to guide clinical practice.

IMPACT

This scoping review has identified gaps in the literature relating to specific eHealth modalities, musculoskeletal diagnoses, and health care utilization data, which should guide future research.

[Innovative interventions in pain physiotherapy : Advancing care for people with chronic pain]

BACKGROUND

Chronic pain, with a prevalence of at least 17%, is a costly health problem associated with a high burden of disease. Musculoskeletal chronic pain is particulary common, which in many cases is treated with physiotherapy.

AIM

The aim of this paper is to provide an overview of innovative, promising physiotherapy interventions in pain management, to present their effectiveness and to discuss their implementation in healthcare.

METHODS

A narrative review was conducted. The Cochrane, Medline (via PubMed) and PEDro databases were searched using the search terms chronic pain, physiotherapy, prevention, pain education, behavioural intervention, eHealth, and systematic review as well as chronic pain, guideline and relevant synonyms.

RESULTS

One guideline review, two guidelines and ten systematic reviews were included. Chronic pain prevention, digital health apps, lifestyle interventions and behavioural approaches were identified as promising and effective interventions for people with chronic pain, showing the potential to meaningfully complement pain physiotherapy and improve quality of care.

CONCLUSIONS

Despite the predominantly positive results from systematic reviews, implementation in everyday care is difficult due to conditions of care and the contemporary education system for physiotherapists in Germany. Health services research can play an important role in accelerating the transfer of innovations into practice.

Development of a Digital Support Application With Evidence-Based Content for Sustainable Return to Work for Persons With Chronic Pain and Their Employers: User-Centered Agile Design Approach

BACKGROUND

Persons with chronic pain experience a lack of support after completing rehabilitation and the responsibility for the return-to-work (RTW) process is taken over by the employer. In addition, employers describe not knowing how to support their employees. Smartphone apps have been increasingly used for self-management, but there is a lack of available eHealth apps with evidence-based content providing digital support for persons with chronic pain and their employers when they return to work.

OBJECTIVE

This study aims to describe the development of a digital support application with evidence-based content that includes a biopsychosocial perspective on chronic pain for sustainable RTW for persons with chronic pain and their employers (SWEPPE [Sustainable Worker Digital Support for Persons With Chronic Pain and Their Employers]).

METHODS

A user-centered agile design approach was applied. The multidisciplinary project team consisted of health care researchers, a user representative, and a software team. A total of 2 reference groups of 7 persons with chronic pain and 4 employers participated in the development process and usability testing. Mixed methods were used for data collection. The design was revised using feedback from the reference groups. The content of SWEPPE was developed based on existing evidence and input from the reference groups.

RESULTS

The reference groups identified the following as important characteristics to include in SWEPPE: keeping users motivated, tracking health status and work situation, and following progress. SWEPPE was developed as a smartphone app for the persons with chronic pain and as a web application for their employers. SWEPPE consists of six modules: the action plan, daily self-rating, self-monitoring graphs, the coach, the library, and shared information with the employer. The employers found the following functions in SWEPPE to be the most useful: employees' goals related to RTW, barriers to RTW, support wanted from the employer, and the ability to follow employees' progress. The persons with chronic pain found the following functions in SWEPPE to be the most useful: setting a goal related to RTW, identifying barriers and strategies, and self-monitoring. Usability testing revealed that SWEPPE was safe, useful (ie, provided relevant information), logical, and easy to use with an appealing interface.

CONCLUSIONS

This study reports the development of a digital support application for persons with chronic pain and their employers. SWEPPE fulfilled the need of support after an interdisciplinary pain rehabilitation program with useful functions such as setting a goal related to RTW, identification of barriers and strategies for RTW, self-monitoring, and sharing information between the employee and the employer. The user-centered agile design approach contributed to creating SWEPPE as a relevant and easy-to-use eHealth intervention. Further studies are needed to examine the effectiveness of SWEPPE in a clinical setting.

Chronic pain self-management in middle-aged and older adults: A collective intelligence approach to identifying barriers and user needs in eHealth interventions

Objectives

eHealth refers to health services and health information delivered or enhanced through the internet and related technologies. The number of eHealth interventions for chronic pain self-management is increasing. However, little evidence has been found for the overall efficacy of these interventions for older adults. The aim of the current study was to use a Collective Intelligence approach to identify the barriers and specific user needs of middle-aged and older adults using eHealth for chronic pain self-management.

Methods

A Collective Intelligence workshop was conducted with middle-aged and older adults to generate, clarify, select, and structure ideas in relation to barriers to eHealth use and specific design requirements for the purposes of chronic pain self-management. Prior to attending the workshop, participants received a trigger question requesting the identification of five barriers to eHealth use for chronic pain self-management. These barriers were categorised and presented to the group along with barrier-related scenarios and user need prompts, resulting in the generation of a set of ranked barriers and a set of user needs.

Results

A total of 78 barriers were identified, from which six categories emerged: Content, Support, Technological, Personal, Computer Literacy and Accessibility. Additional idea-writing and group reflection in response to these barriers revealed 97 user needs.

Conclusion

This is the first study to use Collective Intelligence methods to investigate barriers to eHealth technology use and the specific user needs of middle-aged and older adults in the context of chronic pain self-management. The results of the current study provide a platform for the design and development of enhanced eHealth interventions for this population.

Digital health for quality healthcare: A systematic mapping of review studies

Objective

To systematically catalogue review studies on digital health to establish extent of evidence on quality healthcare and illuminate gaps for new understanding, perspectives and insights for evidence-informed policies and practices.

Methods

We systematically searched PubMed database using sensitive search strings. Two reviewers independently conducted two-phase selection via title and abstract, followed by full-text appraisal. Consensuses were derived for any discrepancies. A standardized data extraction tool was used for reliable data mining.

Results

A total of 54 reviews from year 2014 to 2021 were included with notable increase in trend of publications. Systematic reviews constituted the majority (61.1%, (37.0% with meta-analyses)) followed by scoping reviews (38.9%). Domains of quality being reviewed include effectiveness (75.9%), accessibility (33.3%), patient safety (31.5%), efficiency (25.9%), patient-centred care (20.4%) and equity (16.7%). Mobile apps and computer-based were the commonest (79.6%) modalities. Strategies for effective intervention via digital health included engineering improved health behaviour (50.0%), better clinical assessment (35.1%), treatment compliance (33.3%) and enhanced coordination of care (24.1%). Psychiatry was the discipline with the most topics being reviewed for digital health (20.3%).

Conclusion

Digital health reviews reported findings that were skewed towards improving the effectiveness of intervention via mHealth applications, and predominantly related to mental health and behavioural therapies. There were considerable gaps on review of evidence on digital health for cost efficiency, equitable healthcare and patient-centred care. Future empirical and review studies may investigate the association between fields of practice and tendency to adopt and research the use of digital health to improve care.

Adaptation des pratiques psychologiques en clinique de la douleur durant la pandémie de la COVID-19

Introduction

La pratique clinique auprès de patients douloureux chroniques, ébranlée par la réorganisation du champ sanitaire, a nécessité de repenser la prise en charge psychologique de la douleur. Afin de poursuivre l’accompagnement psychologique des patients, des consultations individuelles ou des ateliers de groupes à distance se sont développés. Un groupe d’échange de pratiques rassemblant des psychologues et psychothérapeutes a partagé ses expériences cliniques et son vécu de la crise.

Objectifs

Les objectifs de cette étude sont d’explorer l’adaptation des pratiques cliniques pour les sujets douloureux chroniques, le vécu des professionnels, et de proposer des recommandations issues des réflexions collectives.

Méthode

La méthodologie de recherche clinique a suivi celle d’un focus group. Trois réunions en visioconférence de deux heures ont eu lieu de septembre 2020 à mai 2021. Une analyse thématique des retranscriptions a été réalisée avec le logiciel d’analyse qualitative NVivo.

Résultats

Au total, 9 psychologues et psychothérapeutes ont participé au focus group. L’analyse thématique a révélé trois grands thèmes, à savoir : (1) impact de la crise sanitaire liée à la COVID-19 ; (2) adaptation des pratiques ; (3) processus de changement des pratiques cliniques.

Conclusion

Les professionnels rapportent que l’usage des outils numériques a permis de limiter l’impact psychologique de la crise sanitaire sur les patients et de maintenir le lien. Des recommandations issues des réflexions collectives suggèrent de maintenir les soins en distanciel et de s’appuyer sur le soutien des équipes, de la hiérarchie, et des groupes d’échanges entre pairs.

The Pain at Work Toolkit for Employees with Chronic or Persistent Pain: A Collaborative-Participatory Study

Self-management tools for people with chronic or persistent pain tend to focus on symptom reporting, treatment programmes or exercise and do not address barriers to work, facilitators of work ability, or workplace pain self-management strategies. We developed the Pain at Work (PAW) toolkit, an evidence-based digital toolkit to provide advice on how employees can self-manage their pain at work. In a collaborative-participatory design, 4-step Agile methodology (N = 452) was used to co-create the toolkit with healthcare professionals, employers and people with chronic or persistent pain. Step 1: stakeholder consultation event (n = 27) established content and format; Step 2: online survey with employees who have persistent pain (n = 274) showed employees fear disclosing their condition, and commonly report discrimination and lack of line manager support. Step 3: online employer survey (n = 107) showed employers rarely provide self-management materials or education around managing pain at work, occupational health recommendations for reasonable adjustments are not always actioned, and pain-related stigma is common. Step 4: Toolkit development integrated findings and recommendations from Steps 1–3, and iterative expert peer review was conducted (n = 40). The PAW toolkit provides (a) evidence-based guidelines and signposting around work-capacity advice and support; (b) self-management strategies around working with chronic or persistent pain, (c) promotion of healthy lifestyles, and quality of life at work; (d) advice on adjustments to working environments and workplace solutions to facilitate work participation.