Digital Therapeutics (DTx) Expand Multimodal Treatment Options for Chronic Low Back Pain: The Nexus of Precision Medicine, Patient Education, and Public Health

Effectiveness of Digital Health Interventions (DHI) in Chronic Pain Management: A Scoping Review of Current Evidence and Emerging Trends

This review aims to address the impact of digital health interventions (DHIs) on chronic pain management, specifically, mHealth, eHealth, wearable devices, virtual reality (VR), and artificial intelligence. The following study identifies and assesses DHIs' efficacy in specific chronic pain conditions and then extrapolates improved outcomes and patient groups that benefit from their use. Using a systematic methodology, this review synthesizes findings that could improve knowledge for patients and practitioners in chronic pain management while also addressing gaps in understanding the impact of DHIs. Sub-questions guide the identification of gaps and recommendations assessing DHIs' effectiveness for pain reduction and improved quality of life. A systematic search across databases (EMBASE, Ovid MEDLINE, CINAHL, Web of Sciences, Cochrane Central) targets original, English-language, peer-reviewed studies (2013-2023). The inclusion criteria cover DHIs in chronic pain management for adults age 18+, excluding non-full texts, reviews, opinion pieces, or unrelated articles. Search terms include "chronic pain management" OR "long-term pain relief strategies" OR "sustained pain alleviation" OR "pain control for chronic conditions" OR "chronic pain" AND "ehealth interventions" OR "mobile health interventions" OR "digital therapy" OR "health informatic solutions" OR "digital health intervention." After applying inclusion criteria, 34 articles from 11 countries are included, with studies conducted primarily in the United States (n = 17), United Kingdom (n = 4), and Australia (n = 3). DHIs are emerging as effective tools in pain management, as they can emphasize patient autonomy and communication with clinicians while enabling medical self-management in diverse populations. These various digital interventions show promise in reducing pharmaceutical usage and deferring surgical procedures, with most studies reporting positive outcomes in pain reduction. DHIs were also associated with positive mental health outcomes; however, some studies found no significant improvement. Additionally, interventions targeting pain catastrophizing showed varied results, with some app-based approaches demonstrating promise. Overall, the review underscores the potential of DHIs in improving chronic pain management outcomes.

Twelve-month results for a randomized sham-controlled effectiveness trial of an in-home skills-based virtual reality program for chronic low back pain

Introduction

Low-risk, accessible, and long-term effective nonpharmacologic behavioral interventions for chronic low back pain (cLBP) are needed. Pain education and cognitive behavioral therapy (CBT) are recommended first-line treatments, but access is poor, treatment effectiveness is variable, and long-term effectiveness is inconsistent. In-home virtual reality (VR)-delivered therapies might address these shortcomings because therapeutic content can be delivered in a consistent and quality-controlled manner.

Objective

To determine whether a 56-session, self-administered in-home, Skills-Based VR program for cLBP (RelieVRx) yields long-term reductions in pain intensity and pain interference 12 months posttreatment in a large demographically diverse and clinically severe real-world sample.

Methods

Participants were 1,093 demographically diverse individuals with self-reported nonmalignant cLBP >3 months duration and average pain intensity and interference scores >4/10. Participants were randomized to Skills-Based VR or active Sham, and data were collected from January 31, 2022 to October 31, 2023. Pretreatment to 12-month posttreatment analyses were conducted.

Results

From baseline to 12 months posttreatment, Skills-Based VR reductions for average pain intensity (1.7 ± 2.1) and pain interference (1.9 ± 2.3) were robust and significantly greater than those found for Sham. More than half of Skills-Based VR participants reported at least a 2-point reduction in pain intensity, pain interference, or both at 12 months posttreatment.

Conclusions

A standardized, in-home Skills-Based VR therapy is effective for reducing pain intensity and pain interference, and these effects are maintained to 12 months posttreatment.

Evolution of treatment for unspecific back pain: From past to future

Unspecific back pain (UBP) has long puzzled medical professionals. Historically, back pain (BP) was often attributed to mystical causes, treated with incantations or herbal concoctions. The Middle Ages shifted towards empirical practices, though still intertwined with superstition, using methods like leeches and bloodletting. The Renaissance introduced systematic healthcare approaches, laying the foundation for modern medicine. The 20th century saw significant advancements with diagnostic imaging, pharmacotherapy, physical therapy, and surgical interventions, though UBP remained elusive. Recent decades have seen a paradigm shift towards multidisciplinary approaches, addressing BP's multifactorial nature through holistic methods considering biomechanical, psychosocial, and lifestyle factors. This shift integrates quantitative research with hermeneutic interpretation, emphasizing evidence-based guidelines. Non-pharmacological interventions such as exercise therapy, electrotherapy, cognitive behavioral therapy, and mindfulness-based stress reduction have gained prominence, empowering individuals in their recovery. Technological innovations like virtual reality and artificial intelligence offer personalized treatment plans, optimizing outcomes. The future of BP treatment holds promise with advancements in regenerative medicine, neuromodulation, telemedicine, and remote monitoring platforms, enhancing accessibility and continuity of care, especially in underserved communities. However, challenges such as the opioid epidemic and healthcare disparities remain, necessitating judicious prescribing practices and equitable resource distribution. The evolving treatment landscape for UBP reflects the dynamic interplay between scientific progress, clinical innovation, and societal needs, aiming to alleviate the burden of back pain and improve quality of life.

Redesigning Pharmacy to Improve Public Health Outcomes: Expanding Retail Spaces for Digital Therapeutics to Replace Consumer Products That Increase Mortality and Morbidity Risks

United States healthcare outcomes, including avoidable mortality rates, are among the worst of high-income countries despite the highest healthcare spending per capita. While community pharmacies contribute to chronic disease management and preventive medicine, they also offer consumer products that increase mortality risks and the prevalence of cardiovascular diseases, diabetes, cancer, and depression. To resolve these contradictions, our perspective article describes opportunities for major pharmacy chains (e.g., CVS Pharmacy and Walgreens) to introduce digital health aisles dedicated to prescription and over-the-counter digital therapeutics (DTx), together with mobile apps and wearables that support disease self-management, wellness, and well-being. We provide an evidence-based rationale for digital health aisles to replace spaces devoted to sugar-sweetened beverages and other unhealthy commodities (alcohol, tobacco) that may increase risks for premature death. We discuss how digital health aisles can serve as marketing and patient education resources, informing customers about commercially available DTx and other technologies that support healthy lifestyles. Since pharmacy practice requires symbiotic balancing between profit margins and patient-centered, value-based care, replacing health-harming products with health-promoting technologies could positively impact prevention of chronic diseases, as well as the physical and mental health of patients and caregivers who visit neighborhood pharmacies in order to pick up medicines.

Digital Therapeutics for Improving Effectiveness of Pharmaceutical Drugs and Biological Products: Preclinical and Clinical Studies Supporting Development of Drug + Digital Combination Therapies for Chronic Diseases

Limitations of pharmaceutical drugs and biologics for chronic diseases (e.g., medication non-adherence, adverse effects, toxicity, or inadequate efficacy) can be mitigated by mobile medical apps, known as digital therapeutics (DTx). Authorization of adjunct DTx by the US Food and Drug Administration and draft guidelines on "prescription drug use-related software" illustrate opportunities to create drug + digital combination therapies, ultimately leading towards drug-device combination products (DTx has a status of medical devices). Digital interventions (mobile, web-based, virtual reality, and video game applications) demonstrate clinically meaningful benefits for people living with Alzheimer's disease, dementia, rheumatoid arthritis, cancer, chronic pain, epilepsy, depression, and anxiety. In the respective animal disease models, preclinical studies on environmental enrichment and other non-pharmacological modalities (physical activity, social interactions, learning, and music) as surrogates for DTx "active ingredients" also show improved outcomes. In this narrative review, we discuss how drug + digital combination therapies can impact translational research, drug discovery and development, generic drug repurposing, and gene therapies. Market-driven incentives to create drug-device combination products are illustrated by Humira® (adalimumab) facing a "patent-cliff" competition with cheaper and more effective biosimilars seamlessly integrated with DTx. In conclusion, pharma and biotech companies, patients, and healthcare professionals will benefit from accelerating integration of digital interventions with pharmacotherapies.

In-Home Virtual Reality Program for Chronic Lower Back Pain: A Randomized Sham-Controlled Effectiveness Trial in a Clinically Severe and Diverse Sample

Objective

To determine whether an 8-week, self-administered in-home, behavioral skills virtual reality program for chronic low back pain (RelieVRx) that trains diaphragmatic breathing, biofeedback, cognition and emotion regulation, mindfulness, and pain education skills, is superior to a strong active Sham at day 56 for improving pain intensity and pain interference, in a large real-world sample.

Patients and Methods

Participants included a national sample of demographically diverse individuals with self-reported nonmalignant chronic low back pain ≥3 months duration with an average pain intensity and pain interference of ≥4/10. Participants were randomized 1:1 to RelieVRx or active Sham, and data were collected from January 31, 2022, to October 31, 2022. We evaluated group differences in brief pain inventory, pain intensity, and pain interference to day 56 (end of treatment).

Results

Of the 1067 participants (772 women, 293 men, and 2 others; mean ± SD age, 50.8±13.2 years) randomized (1:1) into 2 groups: RelieVRx (n=536) and Sham (n=531) comprised the modified intention-to-treat analytic dataset. RelieVRx was superior to Sham for pain intensity and pain interference reductions from pretreatment to day 56 (difference from Sham, pain intensity: 0.406 [0.170-0.642] and pain interference: 0.523 [0.285-0.760]). Pain intensity and interference reductions for RelieVRx at day 56 were clinically meaningful (pain intensity: 2.0 [out of 10] points [1.73-2.06], pain interference: 2.3 points [1.99-2.33]).

Conclusion

An 8-week self-administered behavioral skills virtual reality program was found to impart clinically meaningful improvements above a strong active control comparison on pain intensity and pain interference in clinically severe and diverse adults with chronic low back pain.

Trial Registration

clinicaltrials.gov Identifier: NCT05263037.

Implementation of eLearning solutions for patients with chronic pain conditions

Background

Digital and mobile (mHealth) solutions are online or application-based services intended to support individuals with health needs. Despite evidence supporting the use of mHealth for patients with chronic pain, and the increasing desire of these types of solutions by both patients and providers, adoption of mHealth solutions remains limited. Implementation mapping can serve as a practical method to facilitate implementation and adoption of mHealth solutions within healthcare settings.

Methods

Implementation mapping was used to develop implementation strategies based on contextual determinants organized within the Consolidated Framework for Implementation Research (CFIR) for mHealth eLearning solutions across an integrated, multi-site healthcare system. We describe our experience identifying stakeholders, delineating implementation facilitators and barriers, defining implementation outcomes using RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, outlining initial implementation strategies, and iterating on implementation strategies.

Results

A total of 30 implementation strategies were identified and implemented. Over the first year, primary and specialty care providers across all the clinical sites (n = 70) placed 2559 orders for the mHealth solution. Most patients reported receiving the mHealth eLearning module (74%), and most patients felt that the tool improved their knowledge regarding their condition (82%) and their ability to provide self-care related to the condition (73%).

Conclusion

Practical applications of implementation science methods can help enable change within healthcare settings. Implementation mapping is an exercise that can engage stakeholders to facilitate the incorporation of new methods of care delivery, including mHealth solutions.