Pain Self-Management for Veterans: Development and Pilot Test of a Stage-Based Mobile-Optimized Intervention

Engagement in Digital Self-management Interventions for Chronic Pain: A Systematic Review

OBJECTIVES

Digital interventions promise to increase access to non-pharmacological chronic pain treatment and reduce burden for both individuals seeking care and pain providers/clinics. Unfortunately, despite early evidence of efficacy, engagement in self-management digital interventions for chronic conditions is typically low. A comprehensive analysis into how engagement in these programs is measured and reported is warranted. The current systematic review evaluated engagement in digital self-management interventions for chronic pain and identified gaps to improve reporting of engagement data.

METHODS

We conducted a pre-registered systematic review using Boolean search terms to identify digital chronic pain self-management interventions that did not include clinician support. After removal of duplicates and screening, 150 full-text manuscripts were assessed, and 43 studies met inclusion criteria. Data was extracted and examined from included manuscripts.

RESULTS

Of the 43 included articles, five articles were based on 2 separate datasets, resulting in a final sample of 41 unique datasets representing 4205 participants that were mostly non-Hispanic White, female, and with at least some college education. Approximately 10% of studies did not report any data related to system use or self-reported engagement. Most engagement data consisted of mean system use variables, with a handful of studies describing self-reported use of skills and very few studies examining demographic variables associated with engagement.

DISCUSSION

To address identified gaps in the reviewed literature, we suggest guidelines for collecting and reporting engagement in digital chronic pain interventions. Consistent reporting of engagement data will improve evaluation, efficacy, and improvement of interventions designed to assist individuals who may otherwise not receive non-pharmacological pain treatment.

Development and Use of Mobile Messaging for Individuals With Musculoskeletal Pain Conditions: Scoping Review

BACKGROUND

Population studies show that musculoskeletal conditions are a leading contributor to the total burden of healthy life lost, second only to cancer and with a similar burden to cardiovascular disease. Prioritizing the delivery of effective treatments is necessary, and with the ubiquity of consumer smart devices, the use of digital health interventions is increasing. Messaging is popular and easy to use and has been studied for a range of health-related uses, including health promotion, encouragement of behavior change, and monitoring of disease progression. It may have a useful role to play in the management and self-management of musculoskeletal conditions.

OBJECTIVE

Previous reviews on the use of messaging for people with musculoskeletal conditions have focused on synthesizing evidence of effectiveness from randomized controlled trials. In this review, our objective was to map the musculoskeletal messaging literature more broadly to identify information that may inform the design of future messaging interventions and summarize the current evidence of efficacy, effectiveness, and economics.

METHODS

Following a prepublished protocol developed using the Joanna Briggs Institute Manual for Evidence Synthesis, we conducted a comprehensive scoping review of the literature (2010-2022; sources: PubMed, CINAHL, Embase, and PsycINFO) related to SMS text messaging and app-based messaging for people with musculoskeletal conditions. We described our findings using tables, plots, and a narrative summary.

RESULTS

We identified a total of 8328 papers for screening, of which 50 (0.6%) were included in this review (3/50, 6% previous reviews and 47/50, 94% papers describing 40 primary studies). Rheumatic diseases accounted for the largest proportion of the included primary studies (19/40, 48%), followed by studies on multiple musculoskeletal conditions or pain sites (10/40, 25%), back pain (9/40, 23%), neck pain (1/40, 3%), and "other" (1/40, 3%). Most studies (33/40, 83%) described interventions intended to promote positive behavior change, typically by encouraging increased physical activity and exercise. The studies evaluated a range of outcomes, including pain, function, quality of life, and medication adherence. Overall, the results either favored messaging interventions or had equivocal outcomes. While the theoretical underpinnings of the interventions were generally well described, only 4% (2/47) of the papers provided comprehensive descriptions of the messaging intervention design and development process. We found no relevant economic evaluations.

CONCLUSIONS

Messaging has been used for the care and self-management of a range of musculoskeletal conditions with generally favorable outcomes reported. However, with few exceptions, design considerations are poorly described in the literature. Further work is needed to understand and disseminate information about messaging content and message delivery characteristics, such as timing and frequency specifically for people with musculoskeletal conditions. Similarly, further work is needed to understand the economic effects of messaging and practical considerations related to implementation and sustainability.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2021-048964.

Mobile apps to self-manage chronic low back pain: A realist synthesis exploring what works, for whom and in what circumstances

Objective

Chronic low back pain places a significant burden on healthcare services and sufferers. Clinical guidelines state that it is a condition that requires self-management. This realist synthesis explores how a mobile app could help people to self-manage chronic low back pain.

Method

Six databases and several non-academic sources were searched. In addition, nineteen realist interviews were conducted with stakeholders. Sources were selected and appraised for relevancy, richness, and rigour. Data was coded with analytical memos making retroductive inferences. Causal explanations were presented in context-mechanism-outcome configurations to form three programme theories.

Results

Data from 57 sources was synthesised to create 16 context-mechanism-outcome configurations and presented as three refined programme theories. The findings suggest people need to feel believed before they will engage with a self-management app. For those who feel abandoned by the healthcare service, a self-management app for chronic low back pain can be a valuable source of ongoing support and reduce feelings of social isolation.

Conclusion

A self-management app, if introduced appropriately and as adjunct to care, can be an empowering tool to self-manage chronic low back pain.

Innovation

Using input from key stakeholders enhances our understanding of the hidden generative mechanisms underpinning a programme's success or failure.

Comparison of the effectiveness of eHealth self-management interventions for pain between oncological and musculoskeletal populations: a systematic review with narrative synthesis

OBJECTIVES

The aim of this systematic review is to compare the effectiveness of eHealth self-management interventions on pain intensity between oncological and musculoskeletal populations and to examine barriers and facilitators of the use of eHealth self-management tools.

CONTENT

In March 2021, a systematic search of the literature was conducted using the databases PubMed and Web of Science. Studies that investigated the effect of eHealth self-management interventions on pain intensity in an oncological and/or a musculoskeletal population were included.

SUMMARY

No study was found with a direct comparison of the two populations. Of the ten included studies, only one (musculoskeletal) found a significant interaction effect in favor of the eHealth program and three (musculoskeletal and breast cancer) showed a significant time-effect of the eHealth intervention. In both populations user-friendliness of the tool was considered as a facilitator, the length of the program and the lack of an in-person session as barrier. Due to the absence of a direct comparison, no conclusion can be made on how the effectiveness differs between both populations.

OUTLOOK

Further research should incorporate patient-experienced barriers and facilitators and there is a high need of studies making the direct comparison of the effect of an eHealth self-management intervention on pain intensity in an oncological vs. a MSK population.

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.

Understanding Adoption and Preliminary Effectiveness of a Mobile App for Chronic Pain Management Among US Military Veterans: Pre-Post Mixed Methods Evaluation

Background

The Veterans Health Administration Pain Coach mobile health app was developed to support veterans with chronic pain.

Objective

Our objective was to evaluate early user experiences with the Pain Coach app and preliminary impacts of app use on pain-related outcomes.

Methods

Following a sequential, explanatory, mixed methods design, we mailed surveys to veterans at 2 time points with an outreach program in between and conducted semistructured interviews with a subsample of survey respondents. We analyzed survey data using descriptive statistics among veterans who completed both surveys and examined differences in key outcomes using paired samples t tests. We analyzed semistructured interview data using thematic analysis.

Results

Of 1507 veterans invited and eligible to complete the baseline survey, we received responses from 393 (26.1%). These veterans received our outreach program; 236 (236/393, 60.1%) completed follow-up surveys. We conducted interviews with 10 app users and 10 nonusers. Among survey respondents, 10.2% (24/236) used Pain Coach, and 58% (14/24) reported it was easy to use, though interviews identified various app usability issues. Veterans who used Pain Coach reported greater pain self-efficacy (mean 23.1 vs mean 16.6; P=.01) and lower pain interference (mean 34.6 vs mean 31.8; P=.03) after (vs before) use. The most frequent reason veterans reported for not using the app was that their health care team had not discussed it with them (96/212, 45.3%).

Conclusions

Our findings suggest that future efforts to increase adoption of Pain Coach and other mobile apps among veterans should include health care team endorsement. Our findings regarding the impact of Pain Coach use on outcomes warrant further study.

Predictors of engagement in an internet-based cognitive behavioral therapy program for veterans with chronic low back pain

Internet-based interventions for chronic pain have demonstrated efficacy and may address access barriers to care. Participant characteristics have been shown to affect engagement with these programs; however, limited information is available about the relationship between participant characteristics and engagement with internet-based programs for self-management of chronic pain. The current study examined relationships between demographic and clinical characteristics and engagement with the Pain EASE program, a self-directed, internet-based cognitive behavioral therapy intervention for veterans with chronic low back pain (cLBP). Veterans with cLBP were enrolled in a 10 week trial of the Pain EASE program. Engagement measures included the number of logins, access to coping skill modules, and completed study staff-initiated weekly check-in calls. Regression analyses were conducted to identify significant predictors of engagement from hypothesized predictors (e.g., race/ethnicity, age, depressive symptom severity, and pain interference). Participants (N = 58) were 93% male, 60.3% identified as White, and had a mean age of 54.5 years. Participants logged into the program a median of 3.5 times, accessed a median of 2 skill modules, and attended a median of 6 check-in calls. Quantile regression revealed that, at the 50th percentile, non-White-identified participants accessed fewer modules than White-identified participants (p = .019). Increased age was associated with increased module use (p = .001). No clinical characteristics were significantly associated with engagement measures. White-identified race/ethnicity and increased age were associated with greater engagement with the Pain EASE program. Results highlight the importance of defining and increasing engagement in internet-delivered pain care.

When text simplification is not enough: could a graph-based visualization facilitate consumers' comprehension of dietary supplement information?

Objective

Dietary supplements are widely used. However, dietary supplements are not always safe. For example, an estimated 23 000 emergency room visits every year in the United States were attributed to adverse events related to dietary supplement use. With the rapid development of the Internet, consumers usually seek health information including dietary supplement information online. To help consumers access quality online dietary supplement information, we have identified trustworthy dietary supplement information sources and built an evidence–based knowledge base of dietary supplement information—the integrated DIetary Supplement Knowledge base (iDISK) that integrates and standardizes dietary supplement related information across these different sources. However, as information in iDISK was collected from scientific sources, the complex medical jargon is a barrier for consumers’ comprehension. The objective of this study is to assess how different approaches to simplify and represent dietary supplement information from iDISK will affect lay consumers’ comprehension.

Materials and Methods

Using a crowdsourcing platform, we recruited participants to read dietary supplement information in 4 different representations from iDISK: (1) original text, (2) syntactic and lexical text simplification (TS), (3) manual TS, and (4) a graph–based visualization. We then assessed how the different simplification and representation strategies affected consumers’ comprehension of dietary supplement information in terms of accuracy and response time to a set of comprehension questions.

Results

With responses from 690 qualified participants, our experiments confirmed that the manual approach, as expected, had the best performance for both accuracy and response time to the comprehension questions, while the graph–based approach ranked the second outperforming other representations. In some cases, the graph–based representation outperformed the manual approach in terms of response time.

Conclusions

A hybrid approach that combines text and graph–based representations might be needed to accommodate consumers’ different information needs and information seeking behavior.

Scientific Publication Patterns of Mobile Technologies and Apps for Posttraumatic Stress Disorder Treatment: Bibliometric Co-Word Analysis

Background

Mobile apps are viewed as a promising opportunity to provide support for patients who have posttraumatic stress disorder (PTSD). The development of mobile technologies and apps shows similar trends in PTSD treatment. Therefore, this emerging research field has received substantial attention. Consequently, various research settings are planned for current and further studies.

Objective

The aim of this study was to explore the scientific patterns of research domains related to mobile apps and other technologies for PTSD treatment in scholarly publications, and to suggest further studies for this emerging research field.

Methods

We conducted a bibliometric analysis to identify publication patterns, most important keywords, trends for topicality, and text analysis, along with construction of a word cloud for papers published in the last decade (2010 to 2019). Research questions were formulated based on the relevant literature. In particular, we concentrated on highly ranked sources. Based on the proven bibliometric approach, the data were ultimately retrieved from the Web of Science Core Collection (Clarivate Analytics).

Results

A total of 64 studies were found concerning the research domains. The vast majority of the papers were written in the English language (63/64, 98%) with the remaining article (1/64, 2%) written in French. The articles were written by 323 authors/coauthors from 11 different countries, with the United States predominating, followed by England, Canada, Italy, the Netherlands, Australia, France, Germany, Mexico, Sweden, and Vietnam. The most common publication type was peer-reviewed journal articles (48/64, 75%), followed by reviews (8/64, 13%), meeting abstracts (5/64, 8%), news items (2/64, 3%), and a proceeding (1/64, 2%). There was a mean of 6.4 papers published per year over the study period. There was a 100% increase in the number of publications published from 2016 to 2019 with a mean of 13.33 papers published per year during this latter period.

Conclusions

Although the number of papers on mobile technologies for PTSD was quite low in the early period, there has been an overall increase in this research domain in recent years (2016-2019). Overall, these findings indicate that mobile health tools in combination with traditional treatment for mental disorders among veterans increase the efficiency of health interventions, including reducing PTSD symptoms, improving quality of life, conducting intervention evaluation, and monitoring of improvements. Mobile apps and technologies can be used as supportive tools in managing pain, anger, stress, and sleep disturbance. These findings therefore provide a useful overview of the publication trends on research domains that can inform further studies and highlight potential gaps in this field.

Internet-Based Pain Self-Management for Veterans: Feasibility and Preliminary Efficacy of the Pain EASE Program

OBJECTIVE

To develop and test the feasibility and preliminary efficacy of a cognitive behavioral therapy-based, internet-delivered self-management program for chronic low back pain (cLBP) in veterans.

METHODS

Phase I included program development, involving expert panel and participant feedback. Phase II was a single-arm feasibility and preliminary efficacy study of the Pain e-health for Activity, Skills, and Education (Pain EASE) program. Feasibility (ie, website use, treatment credibility, satisfaction) was measured using descriptive methods. Mixed models were used to assess mean within-subject changes from baseline to 10 weeks post-baseline in pain interference (primary outcome, West Haven-Yale Multidimensional Pain Inventory, scale of 0 to 6), pain intensity, mood, fatigue, sleep, and depression.

RESULTS

Phase I participants (n = 15) suggested modifications including style changes, content reduction, additional "Test Your Knowledge" quizzes, and cognitive behavioral therapy skill practice monitoring form revisions for enhanced usability. In Phase II, participants (n = 58) were mostly male (93%) and White (60%), and had an average age of 55 years (standard deviation [SD] = 12) and moderate pain (mean score 5.9/10); 41 (71%) completed the post-baseline assessment. Participants (N = 58) logged on 6.1 (SD = 8.6) times over 10 weeks, and 85% reported being very or moderately satisfied with Pain EASE. Pain interference improved from a mean of 3.8 at baseline to 3.3 at 10 weeks (difference 0.5 [95% confidence interval 0.1 to 0.9], P = 0.008). Within-subject improvement also occurred for some secondary outcomes, including mood and depression symptoms.

DISCUSSION

Veterans with cLBP may benefit from technology-delivered interventions, which may also reduce pain interference. Overall, veterans found that Pain EASE, an internet-based self-management program, is feasible and satisfactory for cLBP.

Efficacy of mobile application interventions for the treatment of post-traumatic stress disorder: A systematic review

Background

Many adults with post-traumatic stress disorder (PTSD) are unable to access healthcare services for treatment due to logistical, social, and attitudinal barriers. Interventions delivered via mobile applications (apps) may help overcome these barriers.

Objective

The aim of this study is to systematically evaluate the most recent evidence from trials investigating the efficacy of mobile apps for treating PTSD.

Methods

PubMed, Web of Science, Embase, PsycINFO, and Medline were searched in February 2018. Randomised controlled trials (RCTs) were included if they quantitatively evaluated the efficacy of a mobile app for treating PTSD as part of the primary aim. Findings were presented in a narrative synthesis.

Results

In the five identified RCTs, the use of app-based interventions appeared to be associated with reductions in PTSD symptoms. However, the strength of evidence for this association appeared to be inconsistent, and there was little evidence that those using the apps experienced greater reductions in PTSD symptoms than those in control conditions. Nonetheless, there was some evidence that app-based interventions are both a feasible and acceptable treatment pathway option.

Conclusions

Included studies were often limited by small sample sizes, brief intervention, and follow-up periods, and self-reported measures of PTSD. Evidence for the efficacy of mobile interventions for treating PTSD was inconclusive, but promising. Healthcare professionals should exercise caution in recommending app-based interventions until the potentially adverse effects of app use are better understood and larger-scale studies have taken place.