Smartphone apps for the self-management of low back pain: A systematic review

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.

Patient-Facing Mobile Apps to Support Physiotherapy Care: Protocol for a Systematic Review of Apps Within App Stores

Background

Care delivered by physiotherapists aims to facilitate engagement in positive health behaviors by patients (eg, adherence to exercise). However, research suggests that behavioral interventions are frequently omitted from care. Hence, better understanding of strategies that can be used by physiotherapists to support patients to engage in positive behaviors is important and likely to optimize outcomes. Digital health interventions delivered via mobile apps are garnering attention for their ability to support behavior change. They have potential to incorporate numerous behavior change techniques (BCTs) to support goals of physiotherapy care, including but not limited to self-monitoring, goal setting, and prompts/alerts. Despite their potential to support physiotherapy care, much is still unknown about what apps are available to consumers, the BCTs they use, their quality, and their potential to change behaviors.

Objective

The primary aim of this study is to systematically review the mobile apps available in app stores that are intended for use by patients to support physiotherapy care, including the BCTs within these apps. The secondary aims are to evaluate the quality and behavior change potential of these apps.

Methods

A systematic review of mobile apps in app stores will be undertaken. This will be guided by recommendations for systematic reviews in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement but adapted to suit our app store search, consistent with similar systematic reviews of apps published in the Journal of Medical Internet Research. Apple Store and Google Play will be searched with a two-step search strategy, using terms relevant to physiotherapy, physiotherapists, and common physiotherapy care. Key eligibility criteria will include apps that are intended for use by patients and are self-contained or stand-alone without the need of additional wearable devices or other add-ons. Included apps will be coded for BCTs and rated for quality using the Mobile Application Rating Scale (MARS) and for potential to change behavior using the App Behavior Change Scale (ABACUS).

Results

App store search and screening are expected to be completed in 2021. Data extraction and quality appraisal are expected to commence by November 2021. The study results are expected to be published in a subsequent paper in 2022.

Conclusions

Knowledge gained from this review will support clinical practice and inform research by providing a greater understanding of the quality of currently available mobile apps and their potential to support patient behavior change goals of physiotherapy care.

International Registered Report Identifier (IRRID)

PRR1-10.2196/29047

Digital Therapeutic Care and Decision Support Interventions for People With Low Back Pain: Systematic Review

BACKGROUND

Low back pain (LBP) is the leading cause of worldwide years lost because of disability, with a tremendous economic burden for health care systems. Digital therapeutic care (DTC) programs provide a scalable, universally accessible, and low-cost approach to the multidisciplinary treatment of LBP. Moreover, novel decision support interventions such as personalized feedback messages, push notifications, and data-driven activity recommendations amplify DTC by guiding the user through the program while aiming to increase overall engagement and sustainable behavior change.

OBJECTIVE

This systematic review aims to synthesize recent scientific literature on the impact of DTC apps for people with LBP and outline the implementation of add-on decision support interventions, including their effect on user retention and attrition rates.

METHODS

We searched bibliographic databases, including MEDLINE, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database, from March 1, 2016, to October 15, 2020, in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and conducted this review based on related previously published systematic reviews. Besides randomized controlled trials (RCTs), we also included study designs with the evidence level of at least a retrospective comparative study. This enables the consideration of real-world user-generated data and provides information regarding the adoption and effectiveness of DTC apps in a real-life setting. For the appraisal of the risk of bias, we used the Risk of Bias 2 Tool and the Risk of Bias in Non-Randomized Studies of Interventions Tool for the RCTs and nonrandomized trials, respectively. The included studies were narratively synthesized regarding primary and secondary outcome measures, DTC components, applied decision support interventions, user retention, and attrition rates.

RESULTS

We retrieved 1388 citations, of which 12 studies are included in this review. Of the 12 studies, 6 (50%) were RCTs and 6 (50%) were nonrandomized trials. In all included studies, lower pain levels and increased functionality compared with baseline values were observed in the DTC intervention group. A between-group comparison revealed significant improvements in pain and functionality levels in 67% (4/6) of the RCTs. The study population was mostly homogeneous, with predominantly female, young to middle-aged participants of normal to moderate weight. The methodological quality assessment revealed moderate to high risks of biases, especially in the nonrandomized trials.

CONCLUSIONS

This systematic review demonstrates the benefits of DTC for people with LBP. There is also evidence that decision support interventions benefit overall engagement with the app and increase participants' ability to self-manage their recovery process. Finally, including retrospective evaluation studies of real-world user-generated data in future systematic reviews of digital health intervention trials can reveal new insights into the benefits, challenges, and real-life adoption of DTC programs.

Mobile health technologies for the monitoring of menstrual cycle: A systematic review of online stores in Brazil

AIM

To perform a systematic review of available mHealth apps for menstrual cycle monitoring in Brazil.

METHODS

A search for menstrual cycle mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on October 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).

RESULTS

Our review identified 2400 potentially relevant mHealth apps, of which 56 were eligible for inclusion. The majority of the apps offered tools to track menstruation symptoms (63%) and educational content for users (32%). The mean ( ±SD) MARS app quality score for the 28 evaluated apps in Android was 3.5 ± 0.6 on a 0-5 scale. For the 28 evaluated apps in iOS, the mean app quality score was 3.8 ± 0.4. Most of the included apps, for both systems, scored average for credibility, user interface, and engagement.

CONCLUSION

The majority of available tools in Brazil are of moderate quality and limited functionality for menstrual cycle monitoring. This study highlights the top three mHealth apps available on each online store for individuals seeking menstrual cycle monitoring options.

Mobile-based interventions for common mental disorders in youth: a systematic evaluation of pediatric health apps

BACKGROUND

The access to empirically-supported treatments for common mental disorders in children and adolescents is often limited. Mental health apps might extend service supplies, as they are deemed to be cost-efficient, scalable and appealing for youth. However, little is known about the quality of available apps. Therefore, we aimed to systematically evaluate current mobile-based interventions for pediatric anxiety, depression and posttraumatic stress disorder (PTSD).

METHODS

Systematic searches were conducted in Google Play Store and Apple App Store to identify relevant apps. To be eligible for inclusion, apps needed to be: (1) designed to target either anxiety, depression or PTSD in youth (0-18 years); (2) developed for children, adolescents or caregivers; (3) provided in English or German; (4) operative after download. The quality of eligible apps was assessed with two standardized rating systems (i.e., Mobile App Rating Scale (MARS) and ENLIGHT) independently by two reviewers.

RESULTS

Overall, the searches revealed 3806 apps, with 15 mental health apps (0.39%) fulfilling our inclusion criteria. The mean overall scores suggested a moderate app quality (MARS: M = 3.59, SD = 0.50; ENLIGHT: M = 3.22, SD = 0.73). Moreover, only one app was evaluated in an RCT. The correlation of both rating scales was high (r = .936; p < .001), whereas no significant correlations were found between rating scales and user ratings (p > .05).

CONCLUSIONS

Our results point to a rather poor overall app quality, and indicate an absence of scientific-driven development and lack of methodologically sound evaluation of apps. Thus, future high-quality research is required, both in terms of theoretically informed intervention development and assessment of mental health apps in RCTs. Furthermore, institutionalized best-practices that provide central information on different aspects of apps (e.g., effectiveness, safety, and data security) for patients, caregivers, stakeholders and mental health professionals are urgently needed.

Characterisation and assessment of the most popular mobile apps designed for neck pain self-management: A systematic search in app stores

PURPOSE

This study aimed to assess commonly downloaded apps targeting neck pain (NP) using the Mobile Apps Rating Scale (MARS), to characterise the interventions described in the apps and to correlate the ratings of quality retrieved from app stores against the ratings of quality assessed using MARS.

MATERIALS AND METHODS

A systematic search was conducted at the Apple App Store, Google Play, Windows Phone Store and Huawei App Gallery. Mobile apps with 100 or more ratings, a user rating of 4 or higher and which were available for free were retrieved for assessment.

RESULTS

A total of 17 apps met the inclusion criteria. The mean user rating was 4.4 ± 0.28, the mean MARS score was 4.0 ± 0.58 and the correlation between user ratings and MARS total scores and subdomains varied between a maximum of 0.41 (p > 0.05) and a minimum of -0.11 (p > 0.05). All apps included exercise but only 5 (29%) included an educational component.

CONCLUSIONS

The most downloaded apps on NP available for free in app stores are, generally, of acceptable quality as assessed by the MARS total score, target exercise, but fail to include an appropriate educational component. The user rating available in app stores is not an indicator of the quality of the apps. Therefore, health professionals should carefully assess the mobile apps before recommending them to the patients.

Adapted exercises versus general exercise recommendations on chronic low back pain in industrial workers: A randomized control pilot study

BACKGROUND

Exercise has been demonstrated as effective for the treatment of low back pain (LBP) in workers.

OBJECTIVE

The purpose of this study was to investigate whether an exercise program adapted to the characteristics of the workplace is a useful supplement to general exercise recommendations in assembly line workers with chronic LBP.

METHODS

Workers were randomly assigned to intervention group-adapted exercises plus general exercise recommendations (n = 10), and control group-general exercise recommendations (n = 8). Both received 8-week exercise program through a mobile application (APP) to manage the intervention. Outcome was based on lumbar disability (Oswestry Disability Index), interference and lumbar pain intensity (Brief Pain Inventory), and kinematic parameters.

RESULTS

Significant differences were obtained for the intervention group in the "pain interference" variable, in the "mood" and "enjoyment" sub-variables, as well as in "flexion angle" variable. For the control group, significant differences occurred in the "pain intensity" variable. Adapted exercise plus general recommendations seems more effective than the general recommendations for the improvement of lumbar flexion.

CONCLUSIONS

An adapted exercise program for assembly line workers with chronic LBP could be an effective treatment. Future studies with a larger sample size and with an exhaustive control of the exercise adherence are required to confirm the findings of this pilot study.

Back to living well: community-based management of low back pain: a feasibility study

BACKGROUND

Low back pain (LBP) is a long-term health condition with an unpredictable pattern of symptomatic episodes, remission, and recurrence. Recently published systematic reviews suggest that exercise is the most effective intervention for preventing recurrences of LBP in persons that have recovered. Similar programs may also be effective in preventing flare-ups in persistent LBP. The aim of this study was to test the feasibility of the Back to Living Well program (Physical activity + Education + Self-management) developed to prevent recurrence or flare-ups of LBP. The study evaluated feasibility in terms of recruitment rate, adherence, satisfaction with the exercise and education sessions, and the data collection procedures. We also aimed to evaluate barriers and facilitators to the engagement in the program.

METHODS

Seventeen participants with non-specific LBP recently discharged from care from physiotherapy, chiropractors or physician care (< 3 months) were referred to the study by health care providers or community advertisements between December 2018 and February 2019. Participants underwent a 12-week (1 session/week) individualized, group-based exercise in the community and 4 sessions (30 min each) of education. All participants completed an action plan weekly for 12 weeks and wore an activity monitor for 6 months. All participants responded to weekly pain measures and completed study questionnaires at baseline, 3- and 6-months. Feasibility outcomes included recruitment, attrition rates and satisfaction. At the end of the intervention, participants completed an end-of-program survey.

RESULTS

Twenty-nine participants were screened for eligibility; 20 were deemed eligible, while 17 were included over a 2-month period meeting our feasibility targets. In total, 16 completed follow-up study questionnaires at 3 months, and 15 completed the 6-month follow-up. Fourteen participants responded to weekly messages, while 3 participants reported not having a mobile device or Internet access. In total, 15 participants responded to our end-of-program survey. Average age was 54.9 (11.7); 9 were female (53%), and the mean duration of LBP was 62.9 (69.7) months. All satisfaction responses in relation to the exercise program, education program and data collection procedures reached our threshold of 70% out of 100%. Reported barriers to engagement in the program included fear of injury, lack of motivation and travel. Facilitators included proximity to home, low cost, flexible schedule and friendly location.

CONCLUSION

The results show the program is feasible in terms of recruitment, low attrition, and patient satisfaction. Participants highlighted the excellent, relevant education program and the positive, personalized exercise. Future studies should evaluate the effectiveness of this intervention within a fully powered randomized controlled trial.

TRIAL REGISTRATION

NCT03328689.

User-Centered Development of a Mobile App for Biopsychosocial Pain Assessment in Adults: Usability, Reliability, and Validity Study

Background

Pain-related mobile apps targeting pain assessment commonly limit pain assessment to pain behaviors and physiological aspects. However, current guidelines state that pain assessment should follow the biopsychosocial model, clearly addressing biological, psychological, and social aspects of the pain experience. Existing reviews also highlight that pain specialists and end users are not commonly involved in the development process of mobile apps for pain assessment, negatively affecting the quality of the available apps.

Objective

This study aimed to develop a mobile app for pain assessment (AvaliaDor) and assess its usability, validity, reliability, and measurement error in a sample of real patients with chronic pain recruited from a physiotherapy clinic.

Methods

This study was divided into 2 phases: phase 1—development of the AvaliaDor app; and phase 2—assessment of the apps’ usability, reliability, measurement error, and validity. AvaliaDor was developed (phase 1) based on the literature and the recommendations of physiotherapists and patients with pain in cycles of evaluation, inclusion of recommendations, and reevaluation until no further changes were required. The final version of the app was then tested in patients with musculoskeletal pain attending a private physiotherapy practice (phase 2) who were asked to use the app twice on 2 consecutive days for reliability purposes. In addition, participants had to complete a set of paper-based scales (Brief Pain Inventory, painDETECT, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia), which were used to assess the validity (criterion validity and hypothesis testing) of the app, and the Post-Study System Usability Questionnaire was used to assess its usability.

Results

The development process (phase 1) included 5 physiotherapists external to the research team and 5 patients with musculoskeletal pain, and it resulted in the creation of an app named AvaliaDor, which includes an assessment of pain intensity, location, and phenotype; associated disability; and the issues of pain catastrophizing and fear of movement. A total of 52 patients with pain (mean age 50.12 years, SD 11.71 years; 39 females) participated in phase 2 and used the app twice. The Pearson correlation coefficient between the scores on the paper-based scales and the app ranged between 0.81 and 0.93 for criterion validity and between 0.41 and 0.59 for hypothesis testing. Test-retest reliability was moderate to good (intraclass correlation coefficient between 0.67 and 0.90) and the score for usability was 1.16 (SD 0.27), indicating good usability.

Conclusions

A mobile app named AvaliaDor was developed to assess the intensity, location, and phenotype of pain; associated disability; and the issues of pain catastrophizing and fear of movement in a user-centered design process. The app was shown to be usable, valid, and reliable for assessing pain from a biopsychosocial perspective in a heterogeneous group of patients with pain. Future work can explore the long-term use of AvaliaDor in clinical contexts and its advantages for the assessment and management of patients with pain.

A hand exercise mobile app for people with rheumatoid arthritis in Turkey: design, development and usability study

To design and develop a smartphone application for a structured hand exercise programme for patients with rheumatoid arthritis (RA) in Turkey and to test its usability. We followed a two-stage process: (1) Design and Development and (2) Usability testing. In stage 1, we used a qualitative user-centered design approach. We conducted a focus group (8 therapists and people with RA) to discuss the content, features and design to produce a prototype of the application. In a second focus group session, the participants tested the prototype, provided feedback and further revisions were made. In stage 2, 17 participants with RA used the app for 4 to 6 weeks. The System Usability Scale and the adapted Usability, Satisfaction and Ease to Use Questionnaires were used to measure usability, ease of use. Semi-structured interviews were conducted to explore user experiences with the application with 17 participants. In stage 1, the following themes were identified from the focus groups (a) login techniques (b) self-monitoring (c) exercises, (d) exercise diary, (e) information, (f) behavioral change and encouragement (g) exercise adherence. In stage 2, 3 themes were determined from interviews: (a) learning and accuracy, (b) ease of use, (c) motivation and adherence. USE and SUS scores indicated that users reported a high level of usability, satisfaction and ease of use. A mobile app for hand exercise for people with RA was developed using a mixed-method and iterative design. Participants perceived the mobile app as easy to use with high levels of satisfaction.

Systematic evaluation of content and quality of English and German pain apps in European app stores

BACKGROUND AND OBJECTIVE

Pain spans a broad spectrum of diseases and types that are highly prevalent and cause substantial disease burden for individuals and society. Up to 40% of people affected by pain receive no or inadequate treatment. Providing a scalable, time-, and location-independent way for pain diagnostic, management, prevention and treatment mobile health applications (MHA) might be a promising approach to improve health care for pain. However, the commercial app market is rapidly growing and unregulated, resulting in an opaque market. Studies investigating the content, privacy and security features, quality and scientific evidence of the available apps are highly needed, to guide patients and clinicians to high quality MHA.Contributing to this challenge, the present study investigates the content, quality, and privacy features of pain apps available in the European app stores.

METHODS

An automated search engine was used to identify pain apps in the European Google Play and Apple App store. Pain apps were screened and checked for systematic criteria (pain-relatedness, functionality, availability, independent usability, English or German). Content, quality and privacy features were assessed by two independent reviewers using the German Mobile Application Rating Scale (MARS-G). The MARS-G assesses quality on four objectives (engagement, functionality, aesthetics, information quality) and two subjective scales (perceived impact, subjective quality).

RESULTS

Out of 1034 identified pain apps 218 were included. Pain apps covered eight different pain types. Content included basic information, advice, assessment and tracking, and stand-alone interventions. The overall quality of the pain apps was average M = 3.13 (SD = 0.56, min = 1, max = 4.69). The effectiveness of less than 1% of the included pain apps was evaluated in a randomized controlled trial. Major problems with data privacy were present: 59% provided no imprint, 70% had no visible privacy policy.

CONCLUSION

A multitude of pain apps is available. Most MHA lack scientific evaluation and have serious privacy issues, posing a potential threat to users. Further research on evidence and improvements privacy and security are needed. Overall, the potential of pain apps is not exploited.

Mobile Apps for Older Adults: Systematic Search and Evaluation Within Online Stores

Background

Through the increasingly aging population, the health care system is confronted with various challenges such as expanding health care costs. To manage these challenges, mobile apps may represent a cost-effective and low-threshold approach to support older adults.

Objective

This systematic review aimed to evaluate the quality, characteristics, as well as privacy and security measures of mobile apps for older adults in the European commercial app stores.

Methods

In the European Google Play and App Store, a web crawler systematically searched for mobile apps for older adults. The identified mobile apps were evaluated by two independent reviewers using the German version of the Mobile Application Rating Scale. A correlation between the user star rating and overall rating was calculated. An exploratory regression analysis was conducted to determine whether the obligation to pay fees predicted overall quality.

Results

In total, 83 of 1217 identified mobile apps were included in the analysis. Generally, the mobile apps for older adults were of moderate quality (mean 3.22 [SD 0.68]). Four mobile apps (5%) were evidence-based; 49% (41/83) had no security measures. The user star rating correlated significantly positively with the overall rating (r=.30, P=.01). Obligation to pay fees could not predict overall quality.

Conclusions

There is an extensive quality range within mobile apps for older adults, indicating deficits in terms of information quality, data protection, and security precautions, as well as a lack of evidence-based approaches. Central databases are needed to identify high-quality mobile apps.

Pain and Function in Chronic Musculoskeletal Pain-Treating the Whole Person

Chronic pain is often associated with functional limitations that have a huge impact on patients' lives. However, despite being relatively common, chronic musculoskeletal pain is still viewed by some as a symptom of another disease rather than its own condition, and is therefore poorly addressed. This is compounded by other challenges in the field, including education gaps for both healthcare professionals and patients, a lack of universal and comprehensive assessment tools, poor societal perceptions of chronic pain, and the current stigma around the use of opioids. Here, we review the current chronic musculoskeletal pain management landscape in the United States and offer professional insight into emerging methods that can be used to improve patient outcomes, in particular, the achievement of meaningful functional goals. This perspective incorporates our combined multidisciplinary (psychiatry, psychology, nursing, physical therapy, and general medicine) experience and insights. We believe that chronic pain is a multifactorial experience and treatment requires an integrated, multidisciplinary approach from a range of healthcare providers. For the best patient outcomes, this team should work together to assess and treat the patient as a whole, addressing their pain and also providing education, empowerment, and support to enable patients to set and achieve meaningful functional goals that will provide real improvement in their quality of life. We believe that the healthcare community should elevate the conversation around chronic musculoskeletal pain management beyond that of just pain, to encompass the meaningful benefits that improvement in functional outcomes brings to patients.

Mobile health technologies for the management of urinary incontinence: A systematic review of online stores in Brazil

BACKGROUND

Urinary incontinence (UI) is a serious condition for which often times insufficient non-surgical treatment options are provided or sought. Mobile health (mHealth) applications (apps) offer potential to assist with the self-management of UI.

OBJECTIVE

To perform a systematic review of available mHealth apps for UI in Brazil.

METHODS

A search for UI mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 4 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).

RESULTS

Of the 1111 mHealth apps found, 12 were eligible for inclusion. Four offered exclusively exercise programs, six offered exercise and educational content, and two offered tools to track patient-reported symptoms. The included apps scored poorly on the MARS quality scale, with a mean ± standard deviation score of 2.7 ± 0.6 on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement.

CONCLUSION

Although there is growing interest in the development of mHealth technologies to support patients with UI, currently available tools in Brazil are of poor quality and limited functionality. Effective collaboration between industry and research is needed to develop new user-centered mHealth apps that can empower patients with UI.

Mobile health technologies for the management of rheumatic diseases: a systematic review of online stores in Brazil

Rheumatic diseases are serious conditions with a low uptake of conservative treatments. Mobile health (mHealth) applications (apps) offer potential to assist the self-management of rheumatic diseases. Our goal was to perform a systematic review of available mHealth apps for rheumatic diseases in Brazil. We focused on the most prevalent rheumatic diseases: osteoarthritis, rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, osteoporosis, and axial spondylarthritis. Google Play Store and AppStore in Brazil were queried by two independent reviewers on September 2020, and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Of the 3173 mHealth apps found, five were eligible for inclusion. Two for fibromyalgia and two for axial spondylarthritis offered exercise, educational content, and tools to track patient-reported symptoms; and one for osteoporosis offered educational content and tracking tools only. The included apps scored moderately on the MARS quality scale, with a mean score (SD) of 3.1 (0.7) on a 0-5 scale. Most apps scored poorly based on credibility, user interface and experience, and engagement. There is growing interest in the development of mHealth technologies to support rheumatic diseases patients. Although the majority of the included apps came from non-profit organizations, they are still of poor quality and limited functionality. This study is a call for to the development of new user-centered mHealth apps that can empower rheumatic diseases patients in Brazil, especially in the area of osteoarthritis, rheumatoid arthritis, and lupus, since no apps were found.

Going digital: a narrative overview of the effects, quality and utility of mobile apps in chronic disease self-management

Objective Smartphone health applications (apps) are being increasingly used to assist patients in chronic disease self-management. The effects of such apps on patient outcomes are uncertain, as are design features that maximise usability and efficacy, and the best methods for evaluating app quality and utility. Methods In assessing efficacy, PubMed, Cochrane Library and EMBASE were searched for systematic reviews (and single studies if no systematic review was available) published between January 2007 and January 2018 using search terms (and synonyms) of 'smartphone' and 'mobile applications', and terms for each of 11 chronic diseases: asthma, chronic obstructive lung disease (COPD), diabetes, chronic pain, serious mental health disorders, alcohol and substance addiction, heart failure, ischaemic heart disease, cancer, cognitive impairment, chronic kidney disease (CKD). With regard to design features and evaluation methods, additional reviews were sought using search terms 'design', 'quality,' 'usability', 'functionality,' 'adherence', 'evaluation' and related synonyms. Results Of 13 reviews and six single studies assessing efficacy, consistent evidence of benefit was seen only with apps for diabetes, as measured by decreased glycosylated haemoglobin levels (HbA1c). Some, but not all, studies showed benefit in asthma, low back pain, alcohol addiction, heart failure, ischaemic heart disease and cancer. There was no evidence of benefit in COPD, cognitive impairment or CKD. In all studies, benefits were clinically marginal and none related to morbid events or hospitalisation. Twelve design features were identified as enhancing usability. An evaluation framework comprising 32 items was formulated. Conclusion Evidence of clinical benefit of most available apps is very limited. Design features that enhance usability and maximise efficacy were identified. A provisional 'first-pass' evaluation framework is proposed that can help decide which apps should be endorsed by government agencies following more detailed technical assessments and which could then be recommended with confidence by clinicians to their patients. What is known about the topic? Smartphone health apps have attracted considerable interest from patients and health managers as a means of promoting more effective self-management of chronic diseases, which leads to better health outcomes. However, most commercially available apps have never been evaluated for benefits or harms in clinical trials, and there are currently no agreed quality criteria, standards or regulations to ensure health apps are user-friendly, accurate in content, evidence based or efficacious. What does this paper add? This paper presents a comprehensive review of evidence relating to the efficacy, usability and evaluation of apps for 11 common diseases aimed at assisting patients in self-management. Consistent evidence of benefit was only seen for diabetes apps; there was absent or conflicting evidence of benefit for apps for the remaining 10 diseases. Benefits that were detected were of marginal clinical importance, with no reporting of hard clinical end-points, such as mortality or hospitalisations. Only a minority of studies explicitly reported using behaviour change theories to underpin the app intervention. Many apps lacked design features that the literature identified as enhancing usability and potential to confer benefit. Despite a plethora of published evaluation tools, there is no universal framework that covers all relevant clinical and technical attributes. An inclusive list of evaluation criteria is proposed that may overcome this shortcoming. What are the implications for practitioners? The number of smartphone apps will continue to grow, as will the appetite for patients and clinicians to use them in chronic disease self-management. However, the evidence to date of clinical benefit of most apps already available is very limited. Design features that enhance usability and clinical efficacy need to be considered. In making decisions about which apps should be endorsed by government agencies and recommended with confidence by clinicians to their patients, a comprehensive but workable evaluation framework needs to be used by bodies assuming the roles of setting and applying standards.

Barriers and facilitators to patient uptake and utilisation of digital interventions for the self-management of low back pain: a systematic review of qualitative studies

OBJECTIVES

Low back pain (LBP) is a leading contributor to disability globally. Self-management is a core component of LBP management. We aimed to synthesise published qualitative literature concerning digital health interventions (DHIs) to support LBP self-management to: (1) determine engagement strategies, (2) identify barriers and facilitators affecting patient uptake/utilisation and (3) develop a preliminary conceptual model of barriers and facilitators to uptake/utilisation.

DESIGN

Systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

DATA SOURCES

MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, DoPHER, TRoPHI, Web of Science and OT Seeker, from January 2000 to December 2018, using the concepts: LBP, DHI and self-management.

ELIGIBILITY CRITERIA

Peer-reviewed qualitative study (or component) examining engagement with, or barriers and/or facilitators to the uptake/utilisation of an interactive DHI for self-management of LBP in adults (community, primary or secondary care settings).

DATA EXTRACTION AND SYNTHESIS

Standardised data extraction form was completed. COREQ (Consolidated criteria for Reporting Qualitative research) checklist was used to assess methodology. Data was synthesised narratively for engagement strategies, thematically for barriers/facilitators to uptake/utilisation and normalisation process theory was applied to produce a conceptual model.

RESULTS

We identified 14 191 citations, of which 105 full-text articles were screened, and five full-text articles from four studies included. These were from community and primary care contexts in Europe and the USA, and involved 56 adults with LBP and 19 healthcare professionals. There was a lack of consideration on how to sustain engagement with DHIs. Examination of barriers and facilitators for uptake/utilisation identified four major themes: IT (information technology) usability-accessibility; quality-quantity of content; tailoring-personalisation; and motivation-support. These themes informed the development of a preliminary conceptual model for uptake/utilisation of a DHI for LBP self-management.

CONCLUSIONS

We highlight key barriers and facilitators that should be considered when designing DHIs for LBP self-management. Our findings are in keeping with reviews of DHIs for other long-term conditions, implying these findings may not be condition specific.

SYSTEMATIC REVIEW REGISTRATION

A protocol for this systematic review was registered with https://www.crd.york.ac.uk/PROSPERO/ (CRD42016051182) on 10 November 2016. https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016051182.

Outcome measures used in the smartphone applications for the management of low back pain: a systematic scoping review

PURPOSE

Smartphone applications (SPApps) have become a key tool for the self-management of low back pain (LBP). However, the scientific evidence behind the outcome measures used in SPApps for LBP is never investigated before. Therefore, this systematic review firstly assess the quality of the free SPApps for LBP, secondly examines the outcome measures used and thirdly evaluates the outcome measures against the International Classification of Functioning, Disability and Health (ICF) core set classifications for LBP.

METHODS

A systematic scoping review was conducted in the iTunes and Google Play™ on-line stores for LBP SPApps which are free to download. These searches were conducted using keywords suggested by the Cochrane Back and Neck Group. SPApps were screened and downloaded to assess the quality using the Mobile App Rating Scale (MARS). SPApps using outcome measures were reviewed separately to evaluate whether their outcome measures represented any of the ICF components for LBP.

RESULTS

The overall quality of the apps has a mean MARS score of 2.5/5. Out of 74 apps reviewed, only four apps had outcome measures that could be linked to ICF components for LBP. Two of the four categories comprising the LBP core set were well represented.

CONCLUSION

The overall quality of the SPApps for LBP is low. Only very few SPApps offer outcome measures to monitor their effectiveness in the management of LBP. There is very limited evidence to show that the outcome measures used in the apps represents all the four core sets of LBP criteria set by ICF.

Mobile Application-Based Interventions for Chronic Pain Patients: A Systematic Review and Meta-Analysis of Effectiveness

Chronic pain is one of the major causes of disability in the general population. Even though there are effective treatment options available for reducing symptoms, these treatments often do not have consistent lasting effects. As the usage of mobile devices has increased enormously during the last few years, mobile application-based treatment options are widespread. Such app-based programs are not yet empirically proven but might enable patients to become more independent in their pain management in order to prevent relapse. The aim of this meta-analysis was to summarize the literature on mobile application-based interventions for chronic pain patients. Therefore, three electronic bibliographic databases, PubMed, PsycINFO, and Web of Science, were searched for studies that investigated the effectiveness of mobile application-based intervention for chronic pain on pain intensity. The final sample comprised twenty-two studies, with a total of 4679 individuals. Twelve of these twenty-two studies used a randomized control trial (RCT) design, while ten studies only used an observational design. For all twenty-two studies, a small but significant effect (d = -0.40) was found when compared to baseline measures or control groups. The results suggest that apps-based treatment can be helpful in reducing pain, especially in the long-term.

Validation of the Mobile Application Rating Scale (MARS)

BACKGROUND

Mobile health apps (MHA) have the potential to improve health care. The commercial MHA market is rapidly growing, but the content and quality of available MHA are unknown. Instruments for the assessment of the quality and content of MHA are highly needed. The Mobile Application Rating Scale (MARS) is one of the most widely used tools to evaluate the quality of MHA. Only few validation studies investigated its metric quality. No study has evaluated the construct validity and concurrent validity.

OBJECTIVE

This study evaluates the construct validity, concurrent validity, reliability, and objectivity, of the MARS.

METHODS

Data was pooled from 15 international app quality reviews to evaluate the metric properties of the MARS. The MARS measures app quality across four dimensions: engagement, functionality, aesthetics and information quality. Construct validity was evaluated by assessing related competing confirmatory models by confirmatory factor analysis (CFA). Non-centrality (RMSEA), incremental (CFI, TLI) and residual (SRMR) fit indices were used to evaluate the goodness of fit. As a measure of concurrent validity, the correlations to another quality assessment tool (ENLIGHT) were investigated. Reliability was determined using Omega. Objectivity was assessed by intra-class correlation.

RESULTS

In total, MARS ratings from 1,299 MHA covering 15 different health domains were included. Confirmatory factor analysis confirmed a bifactor model with a general factor and a factor for each dimension (RMSEA = 0.074, TLI = 0.922, CFI = 0.940, SRMR = 0.059). Reliability was good to excellent (Omega 0.79 to 0.93). Objectivity was high (ICC = 0.82). MARS correlated with ENLIGHT (ps<.05).

CONCLUSION

The metric evaluation of the MARS demonstrated its suitability for the quality assessment. As such, the MARS could be used to make the quality of MHA transparent to health care stakeholders and patients. Future studies could extend the present findings by investigating the re-test reliability and predictive validity of the MARS.

App-Delivered Self-Management Intervention Trial selfBACK for People With Low Back Pain: Protocol for Implementation and Process Evaluation

Background

Implementation and process evaluation is vital for understanding how interventions function in different settings, including if and why interventions have different effects or do not work at all.

Objective

This paper presents the protocol for an implementation and process evaluation embedded in a multicenter randomized controlled trial conducted in Denmark and Norway (the selfBACK project). selfBACK is a data-driven decision support system that provides participants with weekly self-management plans for low back pain. These plans are delivered through a smartphone app and tailored to individual participants by using case-based reasoning methodology. In the trial, we compare selfBACK in addition to usual care with usual care alone.

Methods

The aim of this study is to conduct a convergent mixed-methods implementation and process evaluation of the selfBACK app by following the reach, effectiveness, adoption, implementation, and maintenance framework. We will evaluate the process of implementing selfBACK and investigate how participants use the intervention in daily life. The evaluation will also cover the reach of the intervention, health care provider willingness to adopt it, and participant satisfaction with the intervention. We will gather quantitative measures by questionnaires and measures of data analytics on app use and perform a qualitative exploration of the implementation using semistructured interviews theoretically informed by normalization process theory. Data collection will be conducted between March 2019 and October 2020.

Results

The trial opened for recruitment in February 2019. This mixed-methods implementation and evaluation study is embedded in the randomized controlled trial and will be collecting data from March 2019 to October 2020; dissemination of trial results is planned thereafter. The results from the process evaluation are expected 2021-2022.

Conclusions

This study will provide a detailed understanding of how self-management of low back pain can be improved and how a digital health intervention can be used as an add-on to usual care to support patients to self-manage their low back pain. We will provide knowledge that can be used to explore the possibilities of extending the generic components of the selfBACK system and key drivers that could be of use in other conditions and diseases where self-management is an essential prevention or treatment strategy.

Trial Registration

ClinicalTrials.gov NCT03798288; https://www.clinicaltrials.gov/ct2/show/NCT03798288

International Registered Report Identifier (IRRID)

DERR1-10.2196/20308

Voice Assistant Reminders for Pain Self-Management Tasks in Aging Adults

Aging adults are impacted by pain. Technology can assist older adults with pain self-management while allowing for independence. The current usability study explored the use of voice assistant reminders for two pain self-management tasks in aging adults. Fifteen community-dwelling older adults with chronic pain and an average age of 65 years used the voice assistant for 4 weeks. Participants had moderate scores for pain severity (mean = 4.6 [SD = 2.3]) and pain interference (mean = 4 [SD = 2.6]). Voice assistant usability was above average (78 of 100). Median time to set up the Google Home Assistant profile was 5 minutes (SD = 7.5), with a median of asking for help two times. Pain self-management task reminders from the voice assistant were perceived as consistent, easy to set up, and helpful for accountability. Voice assistant reminders may be an option to help encourage a variety of pain self-management tasks in aging adults. [Journal of Gerontological Nursing, 46(10), 27-33.].

Issues in reporting of systematic review methods in health app-focused reviews: A scoping review

No guidelines exist for the conduct and reporting of manuscripts with systematic searches of app stores for, and then appraisal of, mobile health apps ('health app-focused reviews'). We undertook a scoping review including a systematic literature search for health app-focused reviews describing systematic app store searches and app appraisal, for apps designed for patients or clinicians. We created a data extraction template which adapted data elements from the PRISMA guidelines for systematic literature reviews to data elements operationalised for health app-focused reviews. We extracted the data from included health app-focused reviews to describe: (1) which elements of the adapted 'usual' methods of systematic review are used; (2) methods of app appraisal; and (3) reporting of clinical efficacy and recommendations for app use. From 2798 records, the 26 included health app-focused reviews showed incomplete or unclear reporting of review protocol registration; use of reporting guidelines; processes of screening apps; data extraction; and appraisal tools. Reporting of clinical efficacy of apps or recommendations for app use were infrequent. The reporting of methods in health app-focused reviews is variable and could be improved by developing a consensus reporting standard for health app-focused reviews.

Usability and Acceptability of an App (SELFBACK) to Support Self-Management of Low Back Pain: Mixed Methods Study

Background

Self-management is the key recommendation for managing nonspecific low back pain (LBP). However, there are well-documented barriers to self-management; therefore, methods of facilitating adherence are required. Smartphone apps are increasingly being used to support self-management of long-term conditions such as LBP.

Objective

The aim of this study was to assess the usability and acceptability of the SELFBACK smartphone app, designed to support and facilitate self-management of non-specific LBP. The app provides weekly self-management plans, comprising physical activity, strength and flexibility exercises, and patient education. The plans are tailored to the patient’s characteristics and symptom progress by using case-based reasoning methodology.

Methods

The study was carried out in 2 stages using a mixed-methods approach. All participants undertook surveys, and semistructured telephone interviews were conducted with a subgroup of participants. Stage 1 assessed an app version with only the physical activity component and a web questionnaire that collects information necessary for tailoring the self-management plans. The physical activity component included monitoring of steps recorded by a wristband, goal setting, and a scheme for sending personalized, timely, and motivational notifications to the user’s smartphone. Findings from Stage 1 were used to refine the app and inform further development. Stage 2 investigated an app version that incorporated 3 self-management components (physical activity, exercises, and education). A total of 16 participants (age range 23-71 years) with ongoing or chronic nonspecific LBP were included in Stage 1, and 11 participants (age range 32-56 years) were included in Stage 2.

Results

In Stage 1, 15 of 16 participants reported that the baseline questionnaire was easy to answer, and 84% (13/16) found the completion time to be acceptable. Overall, participants were positive about the usability of the physical activity component but only 31% (5/16) found the app functions to be well integrated. Of the participants, 90% (14/16) were satisfied with the notifications, and they were perceived as being personalized (12/16, 80%). In Stage 2, all participants reported that the web questionnaire was easy to answer and the completion time acceptable. The physical activity and exercise components were rated useful by 80% (8/10), while 60% (6/10) rated the educational component useful. Overall, participants were satisfied with the usability of the app; however, only 50% (5/10) found the functions to be well integrated, and 20% (2/10) found them to be inconsistent. Overall, 80% (8/10) of participants reported it to be useful for self-management. The interviews largely reinforced the survey findings in both stages.

Conclusions

This study has demonstrated that participants considered the SELFBACK app to be acceptable and usable and that they thought it would be useful for supporting self-management of LBP. However, we identified some limitations and suggestions useful to guide further development of the SELFBACK app and other mobile health interventions.

Efficacy of an innovative smartphone application for office workers with chronic non-specific low back pain: a pilot randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a newly developed evidence-based low back pain (LBP) management smartphone application.

DESIGN

A double-blinded randomized controlled trial where participants randomly assigned to either an experimental group (EG) or a control group (CG).

SETTING

Governmental and private institutions.

PARTICIPANTS

About 40 office workers, aged 30 to 55 years, had pain due to non-specific LBP > 3 on Visual Analogue Scale, and with pain chronicity > 3 months.

INTERVENTIONS

The EG received full version of the application 'Relieve my back' included evidence-based instructions and therapeutic exercises for LBP management, whereas the CG received placebo version included instructions about nutrition.

MAIN MEASURES

Primary outcome measures included pain measured by Visual Analogue Scale (VAS), disability measured by Oswestry Disability Index (ODI), and quality of life measured by Short-Form Health Survey (SF-12).

RESULTS

Following six weeks of using the application, compared to CG, the EG group demonstrated significant decrease in pain intensity (-3.45 (2.21) vs -0.11 (1.66), P < 0.001), in ODI score (-11.05 (10.40) vs -0.58 (9.0), P = 0.002), and significant increase in physical component of SF-12 (12.85 (17.20) vs -4.63 (12.04), P = 0.001).

CONCLUSION

'Relieve my back' application might be efficacious in reducing pain and disability and improving the quality of life of office workers with non-specific LBP.

Mobile-Application-Based Interventions for Patients With Hypertension and Ischemic Heart Disease: A Systematic Review

BACKGROUND

Hypertension and ischemic heart disease are major causes of adult mortality. Related interventions to manage these conditions are important to implement during long, symptom-free periods. The recent proliferation of smartphones has spawned numerous health interventions that rely on mobile applications.

PURPOSE

This systematic review was designed to summarize and analyze research on interventions using mobile applications for patients with hypertension and ischemic heart disease.

METHODS

We searched for related studies published from January 2006 to August 2017 on MEDLINE, EMBASE, CINAHL, and three Korean databases. Seventeen studies were identified and evaluated against eligibility criteria that included a focus on patients with hypertension or ischemic heart disease and a discussion of the detailed effects of a mobile-app-based intervention. All of the identified studies were evaluated qualitatively using a methodology checklist.

RESULTS

Twelve of the 17 studies were deemed as of acceptable quality according to the Scottish Intercollegiate Guideline Network quality assessment. According to the National Institutes of Health quality assessment tool, one article was of fair quality and four articles were of poor quality. Monitoring, education, and reminders were identified as application interventions. The effects of the app interventions were analyzed according to physiological factors, cognitive and behavioral factors, and psychological factors. Of the seven studies that measured blood pressure in patients with hypertension, five studies reported that the app-based interventions reduced blood pressure. Two of three studies showed a significant decrease of body mass index in patients with ischemic heart disease after the app-based interventions compared to the control group. Five of seven studies reported a significant change in medication adherence. Several studies showed different outcomes according to the disease, but the limited number of eligible studies was insufficient to demonstrate a conclusive effect.

CONCLUSIONS

To ensure the long-term effects of mobile-application-based interventions, healthcare professionals should consider the functions of mobile applications. Moreover, because the focus of these interventions may differ based on the nature of the disease, it is recommended that the composition of interventions be tailored to the specific disease.

Can-Pain-a digital intervention to optimise cancer pain control in the community: development and feasibility testing

Purpose

To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing.

Methods

Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app “Can-Pain”. Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks.

Results

Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual.

Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making.

Conclusions

Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial.

Trial registration

Qualitative research: ClinicalTrials.gov, reference NCT02341846

Feasibility study: NIHR CPMS database ID 34172

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05510-0) contains supplementary material, which is available to authorized users.

A digital decision support system (selfBACK) for improved self-management of low back pain: a pilot study with 6-week follow-up

Background

Very few of the publicly available apps directed towards self-management of low back pain (LBP) have been rigorously tested and their theoretical underpinnings seldom described. The selfBACK app was developed in collaboration with end-users and clinicians and its content is supported by best evidence on self-management of LBP. The objectives of this pilot study were to investigate the basis for recruitment and screening procedures for the subsequent randomized controlled trial (RCT), to test the inclusion process in relation to questionnaires and app installation, and finally to investigate the change in primary outcome over time.

Methods

This single-armed pilot study enrolled 51 participants who had sought help for LBP of any duration from primary care (physiotherapy, chiropractic, or general practice) within the past 8 weeks. Participants were screened for eligibility using the PROMIS-Physical-Function-4a questionnaire. Participants were asked to use the selfBACK app for 6 weeks. The app provided weekly tailored self-management plans targeting physical activity, strength and flexibility exercises, and education. The construction of the self-management plans was achieved using case-based reasoning (CBR) methodology to capture and reuse information from previous successful cases. Participants completed the primary outcome pain-related disability (Roland-Morris Disability Questionnaire [RMDQ]) at baseline and 6-week follow-up along with a range of secondary outcomes. Metrics of app use were collected throughout the intervention period.

Results

Follow-up data at 6 weeks was obtained for 43 participants. The recruitment procedures were feasible, and the number needed to screen was acceptable (i.e., 1.6:1). The screening questionnaire was altered during the pilot study. The inclusion process, answering questionnaires and app installation, were feasible. The primary outcome (RMDQ) improved from 8.6 (SD 5.1) at baseline to 5.9 (SD 4.0) at 6-week follow-up (change score 1.8, 95% CI 0.7 to 2.9). Participants spent on average 134 min (range 0–889 min) using the app during the 6-week period.

Conclusion

The recruitment, screening, and inclusion procedures were feasible for the subsequent RCT with a small adjustment. The improvement on the RMDQ from baseline to follow-up was small. Time pattern of app usage varied considerably between the participants.

Trial registration

NCT03697759. Registered on August 10, 2018. https://clinicaltrials.gov/ct2/show/NCT03697759

Factors in the Effectiveness of e-Health Interventions for Chronic Back Pain: How Self-Efficacy Mediates e-Health Literacy and Healthy Habits

Background: Self-management and healthy habits (long-term health-related behaviors) are life-long requirements for the prevention of chronic back pain. Adherence to health interventions is often low because of the target groups' lack of interest. Electronic health (e-Health) information offers an opportunity to solve this issue, but many e-Health interventions are of poor quality. This study explores factors in the effectiveness of e-Health interventions and health-related behavioral changes and, thus, is among the first to develop a theoretical basis for e-Health programs. Materials and Methods: An online survey was conducted among the target groups of primary and secondary health programs promoting the management of possibly chronic back pain in Germany and Austria (N = 224). Measurements of e-Health literacy (eHL), self-efficacy, organized physical exercise, and the patients' social and mental balance were applied in all cases. Participants were categorized into dichotomous subgroups regarding the severity of their back pain. In addition to several significance tests, a correlation analysis and mediation analysis were both performed using PROCESS version 2.0 for SPSS. Results: It was observed in the nonrisk group that self-efficacy has a mediation effect on the connection between eHL and healthy habits. Significant correlations between eHL and self-efficacy in both groups revealed associations between the major driving forces of healthy habits. Conclusion: In keeping with previous research, the findings suggest that a high level of self-efficacy plays a significant role in correctly performing e-Health interventions. Nevertheless, further research should identify the effects of online social surroundings on eHL and self-efficacy in detail.

Effectiveness and cost-effectiveness of stratified blended physiotherapy in patients with non-specific low back pain: study protocol of a cluster randomized controlled trial

BACKGROUND

Patient education, advice on returning to normal activities and (home-based) exercise therapy are established treatment options for patients with non-specific low back pain (LBP). However, the effectiveness of physiotherapy interventions on physical functioning and prevention of recurrent events largely depends on patient self-management, adherence to prescribed (home-based) exercises and recommended physical activity behaviour. Therefore we have developed e-Exercise LBP, a blended intervention in which a smartphone application is integrated within face-to-face care. E-Exercise LBP aims to improve patient self-management skills and adherence to exercise and physical activity recommendations and consequently improve the effectiveness of physiotherapy on patients' physical functioning. The aim of this study is to investigate the short- (3 months) and long-term (12 and 24 months) effectiveness on physical functioning and cost-effectiveness of e-Exercise LBP in comparison to usual primary care physiotherapy in patients with LBP.

METHODS

This paper presents the protocol of a prospective, multicentre cluster randomized controlled trial. In total 208 patients with LBP pain were treated with either e-Exercise LBP or usual care physiotherapy. E-Exercise LBP is stratified based on the risk for developing persistent LBP. Physiotherapists are able to monitor and evaluate treatment progress between face-to-face sessions using patient input from the smartphone application in order to optimize physiotherapy care. The smartphone application contains video-supported self-management information, video-supported exercises and a goal-oriented physical activity module. The primary outcome is physical functioning at 12-months follow-up. Secondary outcomes include pain intensity, physical activity, adherence to prescribed (home-based) exercises and recommended physical activity behaviour, self-efficacy, patient activation and health-related quality of life. All measurements will be performed at baseline, 3, 12 and 24 months after inclusion. An economic evaluation will be performed from the societal and the healthcare perspective and will assess cost-effectiveness of e-Exercise LBP compared to usual physiotherapy at 12 and 24 months.

DISCUSSION

A multi-phase development and implementation process using the Center for eHealth Research Roadmap for the participatory development of eHealth was used for development and evaluation. The findings will provide evidence on the effectiveness of blended care for patients with LBP and help to enhance future implementation of blended physiotherapy.

TRIAL REGISTRATION

ISRCTN, ISRCTN94074203. Registered 20 July 2018 - Retrospectively registered.

Potentials of Digitalization in Sports Medicine: A Narrative Review

Digital transformation is becoming increasingly common in modern life and sports medicine, like many other medical disciplines, it is strongly influenced and impacted by this rapidly changing field. This review aims to give a brief overview of the potential that digital technologies can have for health care providers and patients in the clinical practice of sports medicine. We will focus on mobile applications, wearables, smart devices, intelligent machines, telemedicine, artificial intelligence, big data, system interoperability, virtual reality, augmented reality, exergaming, or social networks. While some technologies are already used in current medical practice, others still have undiscovered potential. Due to the diversity and ever changing nature of this field, we will briefly review multiple areas in an attempt to give readers some general exposure to the landscape instead of a thorough, deep review of one topic. Further research will be necessary to show how digitalization applications could best be used for patient treatments.

The German Version of the Mobile App Rating Scale (MARS-G): Development and Validation Study

BACKGROUND

The number of mobile health apps (MHAs), which are developed to promote healthy behaviors, prevent disease onset, manage and cure diseases, or assist with rehabilitation measures, has exploded. App store star ratings and descriptions usually provide insufficient or even false information about app quality, although they are popular among end users. A rigorous systematic approach to establish and evaluate the quality of MHAs is urgently needed. The Mobile App Rating Scale (MARS) is an assessment tool that facilitates the objective and systematic evaluation of the quality of MHAs. However, a German MARS is currently not available.

OBJECTIVE

The aim of this study was to translate and validate a German version of the MARS (MARS-G).

METHODS

The original 19-item MARS was forward and backward translated twice, and the MARS-G was created. App description items were extended, and 104 MHAs were rated twice by eight independent bilingual researchers, using the MARS-G and MARS. The internal consistency, validity, and reliability of both scales were assessed. Mokken scale analysis was used to investigate the scalability of the overall scores.

RESULTS

The retranslated scale showed excellent alignment with the original MARS. Additionally, the properties of the MARS-G were comparable to those of the original MARS. The internal consistency was good for all subscales (ie, omega ranged from 0.72 to 0.91). The correlation coefficients (r) between the dimensions of the MARS-G and MARS ranged from 0.93 to 0.98. The scalability of the MARS (H=0.50) and MARS-G (H=0.48) were good.

CONCLUSIONS

The MARS-G is a reliable and valid tool for experts and stakeholders to assess the quality of health apps in German-speaking populations. The overall score is a reliable quality indicator. However, further studies are needed to assess the factorial structure of the MARS and MARS-G.

Effectiveness of a Mobile eHealth App in Guiding Patients in Pain Control and Opiate Use After Total Knee Replacement: Randomized Controlled Trial

Background

Little is known about pain and opiate use at home directly after total knee replacement (TKR). Due to adverse effects, low opiate use is desired. An electronic health app (PainCoach) was developed to guide patients in pain control and opiate use.

Objective

The aim of this paper was to investigate the effects of the PainCoach app on pain control and opiate use in patients who underwent TKR during the first 2 weeks at home after surgery.

Methods

In an unblinded randomized controlled trial, patients scheduled for TKR were offline recruited and randomized to a PainCoach group or control group. In the PainCoach group, the PainCoach app was downloaded on each patient’s smartphone or tablet. In response to the patient’s input of the pain experienced, the PainCoach app gave advice on pain medication use, exercises/rest, and when to call the clinic. This advice was the same as that received during usual care. The control group received usual care. The primary outcomes were opiate use and visual analog scale (VAS) pain scores at rest, during activity, and at night during the first 2 weeks at home after surgery, which were collected daily from day 1 until 14 postoperatively by online questionnaires. The actual amount of app use was recorded, and active use was defined as ≥12 total app uses.

Results

The pain scores did not differ between the groups. The PainCoach group (n=38) used 23.2% less opiates (95% CI −38.3 to −4.4; P=.02) and 14.6% more acetaminophen (95% CI 8.2-21.3; P<.001) when compared with the findings in the control group (n=33). The PainCoach app was used 12 (IQR 4.5-22.0) times per patient. In the active PainCoach subgroup (n=19), the following were noted when compared with the findings in the control group: 4.1 times faster reduction of the VAS pain score during activity (95% CI −7.5 to −0.8; P=.02), 6.3 times faster reduction of the VAS pain score at night (95% CI −10.1 to −2.6; P=.001), 44.3% less opiate use (95% CI −59.4 to −23.5; P<.001), 76.3% less gabapentin use (95% CI −86.0 to −59.8; P<.001), and 21.0% more acetaminophen use (95% CI 12.6-30.0; P<.001).

Conclusions

The use of the PainCoach app contributes to reduced opiate use in the initial period at home after TKR. Active use of this app leads to a further reduction in opiate use and improved pain control.

Trial Registration

ClinicalTrials.gov NCT03961152; https://clinicaltrials.gov/ct2/show/NCT03961152

Prescription of individual therapeutic exercises via smartphone app for patients suffering from non-specific back pain : A qualitative feasibility and quantitative pilot study

Background

The purpose of this qualitative study was the assessment of the feasibility and acceptance of orthopedists prescribing individualized therapeutic exercises via a smartphone app to patients suffering from non-specific back pain.

Methods

A total of 27 patients (mean age 44.8 ± 13.2 years) diagnosed with acute non-specific back pain were prescribed individually chosen therapy exercises via a smartphone app. Before the patients started and after 4 weeks of exercising all participants went through an assessment protocol consisting of questionnaires (Oswestry Disability Index [ODI], Short Form-36 [SF-36], International Physical Activity Questionnaire [IPAQ], Work Ability Index [WAI], Visual Analogue Scale [VAS] back pain, sociodemographic parameters), assessment of functional parameters (handgrip strength, timed up and go test). With 16 randomly chosen patients semi-structured interviews were undertaken at the end of the intervention period. Interview transcripts were analyzed using thematic analysis. Power analysis and a priori sample size calculations were undertaken with the quantitative data.

Results

From the interviews four thematic categories emerged: prior exercise experience, evaluation of exercise intensity, communication with physician via smartphone app, and variability of exercise location. Quantitative analysis of secondary data showed significant improvements in back pain (ODI) as well as quality of life domains “physical functioning”, “bodily pain” and “vitality” (SF-36) of which “bodily pain” was sufficiently powered with the current sample size.

Conclusion

The prescription of therapeutic exercises via smartphone app to patients suffering from non-specific back pain is feasible and well-accepted in patients at all ages. Pilot data additionally pointed towards efficacy of the intervention.

Mobile health technologies for the management of systemic lupus erythematosus: a systematic review

OBJECTIVE

We aimed to perform a standardized review of available mobile health (mHealth) applications (apps) for systemic lupus erythematosus (SLE) and to conduct a systematic review of the literature on mHealth technologies in SLE.

METHODS

Google Play and AppStore in the United States of America were queried and the quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS). Web of Science, EMBASE, Medline, and Cochrane databases were systematically searched from inception through June 2019.

RESULTS

Of 324 mHealth apps found, 20 were eligible for inclusion; 10 focused on education, 7 offered tools to track patient-reported symptoms, 5 included interactive online communities, and 1 enabled emoji sharing. The reviewed apps scored poorly on the MARS quality scale with a mean score 2.3 (0.6) out of 5. Of 1147 studies identified in the literature review, 21 were eligible for inclusion; 11 studies (52.4%) focused on the development and use of mHealth for providing patient information, while only 2 (9.5%) were randomized trials of mHealth interventions.

CONCLUSIONS

Although there is growing interest in the development of mHealth technologies to support SLE patients, currently available tools are of poor quality and limited functionality, and the literature examining this area is sparse.

Simulation Training of Orthopaedic Residents for Distal Radius Fracture Reductions Improves Radiographic Outcomes

BACKGROUND

Most distal radius fractures can be treated with closed reduction and casting in pediatric patients. These skills are traditionally developed treating real patients, however, there is growing interest in the use of simulation training to supplement traditional learning strategies.

METHODS

Seventy-eight children with distal radius fractures that underwent closed reduction and casting by novice orthopaedic surgery residents were retrospectively reviewed. Radiographic measures of patients treated by simulation-trained residents were compared with patients treated by residents without simulation training.

RESULTS

Patients treated by simulation-trained residents had less residual angulation in the anteroposterior radiograph (3.7 vs. 6.3 degrees, P=0.006) and translation on the lateral (14% vs. 21%, P=0.040) and anteroposterior radiograph (10% vs. 16%, P=0.029). Patients treated by simulation-trained residents also had lower rates of redisplacement (50% vs. 79%, P=0.016).

CONCLUSIONS

Loss of reduction is common, particularly when novice trainees perform their first independent reductions. Residents who underwent simulation training had lower rates of loss of reduction, thus simulation training has potential as a supplement to the traditional apprentice model of medical education.

LEVEL OF EVIDENCE

Level III.

An App-Delivered Self-Management Program for People With Low Back Pain: Protocol for the selfBACK Randomized Controlled Trial

BACKGROUND

Low back pain (LBP) is prevalent across all social classes, in all age groups, and across industrialized and developing countries. From a global perspective, LBP is considered the leading cause of disability and negatively impacts everyday life and well-being. Self-management is a recommended first-line treatment, and mobile apps are a promising platform to support self-management of conditions like LBP. In the selfBACK project, we have developed a digital decision support system made available for the user via an app intended to support tailored self-management of nonspecific LBP.

OBJECTIVE

The trial aims to evaluate the effectiveness of using the selfBACK app to support self-management in addition to usual care (intervention group) versus usual care only (control group) in people with nonspecific LBP.

METHODS

This is a single-blinded, randomized controlled trial (RCT) with two parallel arms. The selfBACK app provides tailored self-management plans consisting of advice on physical activity, physical exercises, and educational content. Tailoring of plans is achieved by using case-based reasoning (CBR) methodology, which is a branch of artificial intelligence. The core of the CBR methodology is to use data about the current case (participant) along with knowledge about previous and similar cases to tailor the self-management plan to the current case. This enables a person-centered intervention based on what has and has not been successful in previous cases. Participants in the RCT are people with LBP who consulted a health care professional in primary care within the preceding 8 weeks. Participants are randomized to using the selfBACK app in addition to usual care versus usual care only. We aim to include a total of 350 participants (175 participants in each arm). Outcomes are collected at baseline, 6 weeks, and 3, 6, and 9 months. The primary end point is difference in pain-related disability between the intervention group and the control group assessed by the Roland-Morris Disability Questionnaire at 3 months.

RESULTS

The trial opened for recruitment in February 2019. Data collection is expected to be complete by fall 2020, and the results for the primary outcome are expected to be published in fall 2020.

CONCLUSIONS

This RCT will provide insights regarding the benefits of supporting tailored self-management of LBP through an app available at times convenient for the user. If successful, the intervention has the potential to become a model for the provision of tailored self-management support to people with nonspecific LBP and inform future interventions for other painful musculoskeletal conditions.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03798288; https://clinicaltrials.gov/ct2/show/NCT03798288.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14720.

Domains of Chronic Low Back Pain and Assessing Treatment Effectiveness: A Clinical Perspective

Nonspecific chronic low back pain (CLBP) is a common clinical condition that has impacts at both the individual and societal level. Pain intensity is a primary outcome used in clinical practice to quantify the severity of CLBP and the efficacy of its treatment; however, pain is a subjective experience that is impacted by a multitude of factors. Moreover, differences in effect sizes for pain intensity are not observed between common conservative treatments, such as spinal manipulative therapy, cognitive behavioral therapy, acupuncture, and exercise training. As pain science evolves, the biopsychosocial model is gaining interest in its application for CLBP management. The aim of this article is to discuss our current scientific understanding of pain and present why additional factors should be considered in conservative CLBP management. In addition to pain intensity, we recommend that clinicians should consider assessing the multidimensional nature of CLBP by including physical (disability, muscular strength and endurance, performance in activities of daily living, and body composition), psychological (kinesiophobia, fear-avoidance, pain catastrophizing, pain self-efficacy, depression, anxiety, and sleep quality), social (social functioning and work absenteeism), and health-related quality-of-life measures, depending on what is deemed relevant for each individual. This review also provides practical recommendations to clinicians for the assessment of outcomes beyond pain intensity, including information on how large a change must be for it to be considered "real" in an individual patient. This information can guide treatment selection when working with an individual with CLBP.

Implementation and Evaluation of a Web-Based Distribution System For Anesthesia Department Guidelines and Standard Operating Procedures: Qualitative Study and Content Analysis

BACKGROUND

Digitization is spreading exponentially in medical care, with improved availability of electronic devices. Guidelines and standard operating procedures (SOPs) form an important part of daily clinical routine, and adherence is associated with improved outcomes.

OBJECTIVE

This study aimed to evaluate a digital solution for the maintenance and distribution of SOPs and guidelines in 2 different anesthesiology departments in Switzerland.

METHODS

A content management system (CMS), WordPress, was set up in 2 tertiary-level hospitals within 1 year: the Department of Anesthesiology and Pain Medicine at the Kantonsspital Lucerne in Lucerne, Switzerland, as an open-access system, followed by a similar system for internal usage in the Department of Anaesthesiology and Pain Medicine of the Inselspital, Bern University Hospital, in Bern, Switzerland. We analyzed the requirements and implementation processes needed to successfully set up these systems, and we evaluated the systems' impact by analyzing content and usage.

RESULTS

The systems' generated exportable metadata, such as traffic and content. Analysis of the exported metadata showed that the Lucerne website had 269 pages managed by 44 users, with 88,124 visits per month (worldwide access possible), and the Bern website had 341 pages managed by 35 users, with 1765 visits per month (access only possible from within the institution). Creation of an open-access system resulted in third-party interest in the published guidelines and SOPs. The implementation process can be performed over the course of 1 year and setup and maintenance costs are low.

CONCLUSIONS

A CMS, such as WordPress, is a suitable solution for distributing and managing guidelines and SOPs. Content is easily accessible and is accessed frequently. Metadata from the system allow live monitoring of usage and suggest that the system be accepted and appreciated by the users. In the future, Web-based solutions could be an important tool to handle guidelines and SOPs, but further studies are needed to assess the effect of these systems.

Low back pain websites do not meet the needs of consumers: A study of online resources at three time points

BACKGROUND

The popularity of the Internet as a source of health-related information for low back pain (LBP) is growing. Although research has evaluated information quality in health-related websites, few studies have considered whether content and presentation match consumer preferences.

OBJECTIVE

The aim of this study was to evaluate whether LBP website content and presentation matched preferences of consumers with LBP, whether matching preference of consumers changed over 8 years as recognition of people-centred healthcare has developed and whether this differs between countries of Internet searching.

METHOD

The most prominent and top 20 LBP websites were identified using common search engines in 2010, 2015 and 2018. Websites identified in the top 20 in 2010 were followed up if not identified in 2015 and 2018. Two reviewers independently evaluated websites with a 16-item checklist developed from research of consumer preferences. In 2015, websites were identified using searches conducted using IP addresses from Australia, the United States of America (USA), the United Kingdom and Canada. After removal of duplicates, 55 websites were evaluated in 2010. In 2015 and 2018, 33 and 28 new sites, respectively, were identified, and 37 previous websites were re-evaluated.

RESULTS

In 2010 and 2015, websites predominantly originated from USA and were sponsored by "for-profit" organisations. In 2018, most websites originated from Australian "not-for-profit" organisations. None of the websites provided information on all content areas. At least 55% of websites were rated as poor or fair. No site rated as excellent overall. There was some worsening over time. Country of search did not affect results.

CONCLUSION

Websites retrieved using typical searches did not meet information and presentation preferences of people with LBP.

Comparative Efficacy of Clinic-Based and Telerehabilitation Application of Mckenzie Therapy in Chronic Low-Back Pain

Studies on validation of telerehabilitation as an effective platform to help manage as well as reduce burden of care for Low-Back Pain (LBP) are sparse. This study compared the effects of Telerehabilitation-Based McKenzie Therapy (TBMT) and Clinic-Based McKenzie Therapy (CBMT) among patients with LBP. Forty-seven consenting patients with chronic LBP who demonstrated 'directional preference' for McKenzie Extension Protocol (MEP) completed this quasi experimental study. The participants were assigned into either the CBMT or TBMT group using block permuted randomization. Participants in the CBMT and TBMT groups received MEP involving a specific sequence of lumbosacral repeated movements in extension aimed to centralize, decrease, or abolish symptoms, thrice weekly for eight weeks. TBMT is a comparable version of CBMT performed in the home with the assistance of a mobile phone app. Outcomes were assessed at the 4th and 8th weeks of the study in terms of Pain Intensity (PI), Back Extensors Muscles' Endurance (BEME), Activity Limitation (AL), Participation Restriction (PR), and General Health Status (GHS). Data were analyzed using descriptive and inferential statistics. Alpha level was set at p< 0.05. Within-group comparison across baseline, 4^th and 8^th weeks indicate that both CBMT and TBMT had significant effects on PI (p=0.001), BEME (p=0.001), AL (p=0.001), PR (p=0.001) and GHS (p=0.001) respectively. However, there were no significant differences (p>0.05) in the treatment effects between TBMT and CBMT, except for 'vitality' (p=0.011) scale in the GHS where TBMT led to significantly higher mean score. Mobile-app platform of the McKenzie extension protocol has comparable clinical outcomes with the traditional clinic-based McKenzie Therapy, and thus is an effective supplementary platform for care of patients with low-back pain.

Mobile applications for pain management: an app analysis for clinical usage

BACKGROUND

Pain is the most common and distressing symptom for patients in all clinical settings. The dearth of health informatics tools to support acute and chronic pain management may be contributing to the chronic pain and opioid abuse crises. The purpose of this study is to qualitatively evaluate the content and functionality of mobile pain management apps.

METHODS

The Apple App Store and the Google Play Store were searched to identify pain management apps. The inclusion criteria were as follows: (1) that apps include a pain diary function allowing users to record pain episodes, (2) are available in either Apple App Store or Google Play Store, and (3) are available in the English language. We excluded apps if they were limited to only specific forms of pain or specific diseases.

RESULTS

A total of 36 apps met the inclusion criteria. Most of the apps served as pain diary tools to record the key characteristics of pain. The pain diary features of the apps were grouped into nine categories: the recordings of pain intensity, pain location, pain quality, pain's impacts on daily life, other features of pain, other related symptoms, medication, patients' habits and basic information, and other miscellaneous functions. The apps displayed various problems in use. The problem of not involving healthcare professionals in app development has not been resolved. Approximately 31% of apps including a pain diary function engaged clinicians in app development. Only 19% involved end-users in development and then only in an ad-hoc way. Only one third of the apps supported the cross-platforms, none of the apps supported clinician access to graphical pain data visualization, none secured HIPAA compliance, and none endorsed the PEG tool for primary care physicians' chronic pain management.

CONCLUSIONS

Most of the 36 pain management apps demonstrated various problems including user interface and security. Many apps lacked clinician and end-user involvement in app development impacting the clinical utility of these apps. We could not find any pain apps suitable for clinical usage despite high demand from clinicians due to the US opioid crisis.

Evaluation of Self-Management Support Functions in Apps for People With Persistent Pain: Systematic Review

Background

Smartphone apps are a potential mechanism for development of self-management skills in people with persistent pain. However, the inclusion of best-practice content items in available pain management apps fostering core self-management skills for self-management support is not known.

Objective

The aim of the study was to evaluate the contents of smartphone apps providing information on pain management strategies for people with persistent pain facilitating self-management support and to appraise the app quality.

Methods

A systematic search was performed in the New Zealand App Store and Google Play Store. Apps were included if they were designed for people with persistent pain, provided information on pain self-management strategies, and were available in English. App contents were evaluated using an a priori 14-item self-management support (SMS-14) checklist. App quality was assessed using the 23-item Mobile Apps Rating Scale.

Results

Of the 939 apps screened, 19 apps met the inclusion criteria. Meditation and guided relaxation were the most frequently included self-management strategies. Overall, the included apps met a median of 4 (range 1-8) of the SMS-14 checklist. A total of 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) met the largest number of items (8 out of 14) to foster self-management of pain. Self-monitoring of symptoms (n=11) and self-tailoring of strategies (n=9) were frequently featured functions, whereas a few apps had features facilitating social support and enabling communicating with clinicians. No apps provided information tailored to the cultural needs of the user. The app quality mean scores using Mobile Apps Rating Scale ranged from 2.7 to 4.5 (out of 5.0). Although use of 2 apps (Headspace and SuperBetter) has been shown to improve health outcomes, none of the included apps have been evaluated in people with persistent pain.

Conclusions

Of the 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) that met the largest number of items to support skills in self-management of pain, 2 apps (PainScale-Pain Diary and Coach and SuperBetter) were free, suggesting the potential for using apps as a scalable, wide-reaching intervention to complement face-to-face care. However, none provided culturally tailored information. Although 2 apps (Headspace and SuperBetter) were validated to show improved health outcomes, none were tested in people with persistent pain. Both users and clinicians should be aware of such limitations and make informed choices in using or recommending apps as a self-management tool. For better integration of apps in clinical practice, concerted efforts are required among app developers, clinicians, and people with persistent pain in developing apps and evaluating for clinical efficacy.

A review of pregnancy iPhone apps assessing their quality, inclusion of behaviour change techniques, and nutrition information

Smartphone apps for use in pregnancy are common and could influence lifestyle behaviours, but they have not been evaluated. This review aimed to assess the quality of iPhone pregnancy apps and whether they included behaviour change techniques (BCTs) and/or pregnancy-specific nutrition information. A keyword search of the Australian iTunes app store was conducted. For inclusion, apps had to be available at no cost, in English, intended for use by pregnant women, and contain nutrition information. App quality was assessed using the Mobile Application Rating Scale (MARS). Absence or presence of BCTs was assessed using the CALO-RE taxonomy, with type of nutrition information included also reported. The initial key word search identified 607 apps, with 51 iPhone apps included in final evaluation. Mean overall MARS quality rating score was 3.05 out of 5 (1 = inadequate; 5 = excellent). The functionality subscale scored highest (mean = 3.32), and aesthetics scored lowest (mean = 2.87). Out of a possible 40 BCTs, 11 were present across the apps with a median of three BCTs (range: 0-6) identified per app. The median number of pregnancy-specific nutrition topics per app was three (range 0 to 7). Despite the availability of a large number of iPhone pregnancy apps, few are of high quality, with only a small number of BCTs used and limited inclusion of pregnancy-specific nutrition information. It is important to be aware of limitations within current pregnancy apps before recommending usage during this key life stage.

Use of Health Apps and Wearable Devices: Survey Among Italian Associations for Patient Advocacy

BACKGROUND

Technological tools such as Web-based social networks, telemedicine, apps, or wearable devices are becoming more widespread in health care like elsewhere. Although patients are the main users, for example, to monitor symptoms and clinical parameters or to communicate with the doctor, their perspective is seldom analyzed, and to the best of our knowledge, no one has focused on the patients' health care advocacy associations' point of view.

OBJECTIVE

The objective of this study was to assess patients' health care advocacy associations' opinions about the use, usefulness, obstacles, negative aspects, and impact of health apps and wearable devices through a Web-based survey.

METHODS

We conducted a Web-based survey through SurveyMonkey over nearly 3 months. Participants were contacted via an email explaining the aims of the survey and providing a link to complete the Web-based questionnaire. All the 20 items were mandatory, and the anonymized data were collected automatically into a database. Only fully completed questionnaires were considered for analysis.

RESULTS

We contacted 1998 patients' health care advocacy associations; a total of 258 questionnaires were received back (response rate 12.91%), and 227 of the received questionnaires were fully completed (completion rate 88.0%). Informative apps, hospital apps for viewing medical reports or booking visits, and those for monitoring physical activity are the most used. They are considered especially useful to improve patients' engagement and compliance with treatment. Wearable devices to check physical activity and glycemia are the most widespread considering, again, their benefits in increasing patients' involvement and treatment compliance. For health apps and wearable devices, the main obstacles to their use are personal and technical reasons; the risk of overmedicalization is considered the most negative aspect of their constant use, while privacy and confidentiality of data are not rated a limitation. No statistical difference was found on stratifying the answers by responders' technological level (P=.30), age (P=.10), and the composition of the association's advisory board (P=.15).

CONCLUSIONS

According to responders, health apps and wearable devices are sufficiently known and used and are considered potential supports for greater involvement in health management. However, there are still obstacles to their adoption, and the developers need to work to make them more accessible and more useful. The involvement of patients and their associations in planning services and products based on these technologies (as well as others) would be desirable to overcome these barriers and boost awareness about privacy and the confidentiality of data.

Physical Therapy Approaches in the Treatment of Low Back Pain

Globally, in 2016, low back pain (LBP) contributed 57.6 million of total years lived with disability. Low Back Pain Guidelines regularly recommend the use of physical exercise for non-specific LBP. Early non-pharmacological treatment is endorsed. This includes education and self-management, and the recommencement of normal activities and exercise, with the addition of psychological programs in those whose symptoms persist. The aim of physical treatments is to improve function and prevent disability from getting worse. There is no evidence available to show that one type of exercise is superior to another, and participation can be in a group or in an individual exercise program. Active strategies such as exercise are related to decreased disability. Passive methods (rest, medications) are associated with worsening disability, and are not recommended. The Danish, United States of America, and the United Kingdom Guidelines recommend the use of exercise on its own, or in combination with other non-pharmacological therapies. These include tai chi, yoga, massage, and spinal manipulation. Public health programs should educate the public on the prevention of low back pain. In chronic low back pain, the physical therapy exercise approach remains a first-line treatment, and should routinely be used.

The Perceived Benefits of an Artificial Intelligence-Embedded Mobile App Implementing Evidence-Based Guidelines for the Self-Management of Chronic Neck and Back Pain: Observational Study

Background

Chronic musculoskeletal neck and back pain are disabling conditions among adults. Use of technology has been suggested as an alternative way to increase adherence to exercise therapy, which may improve clinical outcomes.

Objective

The aim was to investigate the self-perceived benefits of an artificial intelligence (AI)–embedded mobile app to self-manage chronic neck and back pain.

Methods

A total of 161 participants responded to the invitation. The evaluation questionnaire included 14 questions that were intended to explore if using the AI rehabilitation system may (1) increase time spent on therapeutic exercise, (2) affect pain level (assessed by the 0-10 Numerical Pain Rating Scale), and (3) reduce the need for other interventions.

Results

An increase in time spent on therapeutic exercise per day was observed. The median Numerical Pain Rating Scale scores were 6 (interquartile range [IQR] 5-8) before and 4 (IQR 3-6) after using the AI-embedded mobile app (95% CI 1.18-1.81). A 3-point reduction was reported by the participants who used the AI-embedded mobile app for more than 6 months. Reduction in the usage of other interventions while using the AI-embedded mobile app was also reported.

Conclusions

This study demonstrated the positive self-perceived beneficiary effect of using the AI-embedded mobile app to provide a personalized therapeutic exercise program. The positive results suggest that it at least warrants further study to investigate the physiological effect of the AI-embedded mobile app and how it compares with routine clinical care.

Smartphone apps for total hip replacement and total knee replacement surgery patients: a systematic review

Purpose: The aim of this study was to critically examine the content of smartphone apps produced for patients undergoing total hip replacement and total knee replacement surgery.Materials and methods: A systematic search was conducted across the five most popular smartphone app stores: iTunes; Google Play; Windows Mobile; Blackberry App World; and Nokia Ovi. Apps were identified for screening if they: targeted total hip replacement or total knee replacement patients; were free of charge; and were in English. App quality assessment was conducted independently by three reviewers using the Mobile App Rating Scale.Results: 15 apps met the inclusion criteria. On the 5-point Mobile App Rating Scale, the mean overall app quality score was 3.1. Within the Mobile App Rating Scale, the "Aesthetics" subscale had the most inconsistency across all apps, generating the highest and lowest mean scores (4.7 and 1, respectively). The "functionality" subscale had the highest mean score (3.8) among the four subscales, and the "information" subscale had the lowest mean score (2.7).Conclusion: This study highlights that despite a wide range of apps currently available to total hip replacement and total knee replacement patients, there is significant variability in their quality. Future efforts should be made to develop apps in partnership with patients, to improve the content, interactivity and relevance of apps.Implications for RehabilitationClinicians and rehabilitation professionals should consider that patients are using Smartphone apps to supplement their rehabilitation and be aware of currently available apps.Although some apps show promise, at present there is no one openly available app which is clinically recommended for rehabilitation use following total hip replacement and total knee replacement.Rehabilitation professionals tailor recovery programmes to individual patient needs following total hip replacement and total knee replacement, and future apps should also consider personal needs.We recommend that patients are involved in all stages of designing and testing future total hip replacement and total knee replacement rehabilitation apps.