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

Examining Resilient Pain Behaviors for Chronic Low Back Pain: A Scoping Review

OBJECTIVES

The objective of this scoping review was to examine resilience and resilient pain behaviors for those with CLBP in relation to resilience definitions, operationalization (e.g. trait or behavior), and application of theoretical frameworks.

DESIGN

This scoping review examined resilience and resilient pain behaviors for those with CLBP in relation to resilience definitions, operationalization (e.g. trait or behavior), and application of theoretical frameworks.

DATA SOURCES

To gather data, we used five databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Ovid MEDLINE, PsycInfo, and Scopus.

REVIEW/ANALYSIS METHODS

Authors used a systematic data charting spreadsheet (Microsoft Excel) to review and analyze the extracted data.

RESULTS

A total of 26 articles, from 2011-2021, were included in the final analysis. A majority of articles were conducted in the United States (11) and cross-sectional secondary data analysis design (13). Resilience definitions varied across the studies. Three studies operationalized resilience as a trait and only one as a behavior. Most studies (20) did not include a theoretical framework.

CONCLUSION

The majority cross-sectional design and heterogeneity of a resilience definition indicates resilience research is still emerging. The lack of operationalized resilience, specifically as a behavior, and the limited use of theoretical frameworks suggest advancements in resilience pain research are needed.

NURSING PRACTICE IMPLICATIONS

This research has implications for nursing practice to support nurse's holistic perspective and the ability to incorporate resilience within nursing care. This research provides the initial steps to developing standard resilience definitions and frameworks to guide nursing practice.

Implementation of back to living well, a community-based program for the tertiary prevention of low back pain: a study protocol

BACKGROUND

The current literature supports the effectiveness of exercise, education, and self-management interventions for the long-term management of persistent low back pain. However, there is significant uncertainty about the implementation of interventions related to barriers, facilitators, and patient's preferences. This study will evaluate the Back to Living Well program implementation from a participant and organizational perspective. More specifically we address the following objectives: 1) identify program barriers and facilitators from participants' perspectives, 2) identify factors related to program, personal and contextual factors that contribute to negative and positive outcomes, and outcome trajectories, 3) identify factors influencing participants' selection of an in-person or e-health program, and 4) evaluate program specific barriers and facilitators from the organization and care delivery perspectives.

METHODS

This study will utilize a mixed-method convergent design including a longitudinal cohort strand and a longitudinal qualitative interview strand. The RE-AIM framework will be used to assess program implementation. Participants (n = 90, 1:1: in person or virtual) who choose to register in the program as well as staff (n = 10 to 15) involved in the delivery of the program will be invited to participate. Participants will participate in a 12-week physical activity, education, and self-management program. Implementation outcomes will be measured at 3-, 6-, 12-months, and six months after the end of the follow-ups. Interview scripts and directed content analysis will be constructed based on the Theoretical Domains Framework and the Neuromatrix Model of Pain, Theoretical Domains Framework. Staff interviews will be constructed and analyzed using the Consolidated Framework for Implementation Research. Participants will also complete pain, disability, quality of life and psychological questionnaires, wear an activity tracker at all time points, and complete weekly pain and activity limitation questions using a mobile application.

DISCUSSION

The study results will provide evidence to inform potential future implementation of the program. An effective, appropriately targeted, and well implemented exercise program for the long-term management (i.e., tertiary prevention) of LBP could minimize the burden of the condition on patients, the health care system and society.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05929846. This (Registration Date: July 3 2023) study has been approved by the Hamilton Integrated Research Ethics Board Project ID#15,354.

Mobile Application Applied for Cognitive Rehabilitation: A Systematic Review

The COVID-19 pandemic has increased the demand for home rehabilitation services, leading to the development and rising demand for cognitive rehabilitation apps. However, a comprehensive analysis of the content and effectiveness of these apps is needed. This study systematically reviewed and analyzed the literature on mobile apps for cognitive rehabilitation. One researcher and an external expert conducted the study selection, data extraction, and quality assessment following the PRISMA Checklist 2020 guidelines. Our review of 18 studies identified 8 randomized controlled trials (RCTs) (44.44%) of high quality and 10 non-RCT studies (55.56%) of moderate quality. Overall, 16 of the 18 studies (88.88%) demonstrated positive clinical implications for cognitive function after using cognitive rehabilitation apps. Eight studies showed a correlation between app use and improved cognitive function, and four highlighted the potential for cognitive function evaluation through apps. All studies employed various occupational therapy (OT) intervention approaches, with prevention being the most common (100%), followed by establishment and restoration (83.33%), maintenance (77.77%), and creation and promotion (38.88%). This study clinically validates the effectiveness of cognitive rehabilitation mobile applications from an occupational therapy perspective.

Low back pain self-management mobile applications: a systematic review on digital platforms

OBJECTIVE

To identify and analyze the features and quality of self-management support of mobile applications available in Brazil for chronic low back pain in adults.

METHOD

A systematic review on the Apple Store® and Google Play® digital platforms. The Self-Management Support Assessment Tool scale was used to assess self-management support and the Institute for Healthcare Informatics Functionality Score scale was used to assess functionality.

RESULTS

Seventeen applications were selected, which included around seven self-management skills. The applications that met the majority of self-management support skills were Pathways, Branch, Pancea, Pain Navigator, and Curable. The Curable, Branch and MoovButh applications had the highest scores, with ten features on the functionality scale.

CONCLUSION

Some applications have the potential to complement in-person treatment in terms of validity, acceptability and clinical usefulness in pain management. However, barriers such as lack of partnership between healthcare providers and patients, limited evidence-based content, social support, cultural relevance, cost, language, security and privacy can limit their sustained use. PROSPERO Registration: CRD42022382686.

The Efficacy of the Smartphone App for the Self-Management of Low Back Pain: A Systematic Review and Assessment of Their Quality through the Mobile Application Rating Scale (MARS) in Italy

Smartphone apps for self-management are valuable tools to help manage low back pain (LBP) patients. The purposes of this systematic review were to (a) summarize the available studies on the efficacy of smartphone apps for self-management of LBP and (b) identify free applications available in Italy that offer strategies for LBP self-management and provide a qualitative assessment using the Mobile Application Rating Scale (MARS). According to the Prisma Checklist, six bibliographic databases were searched with the keywords 'low back pain', 'mobile application', 'smartphone', and 'telemedicine'. In total, 852 records were screened, and 16 were included in the systematic review. Of the six RCTs included, four reported a statistically significant decrease in pain in favor of the app group, and two RCTs did not. Only in a non-RCT was there an increase in the disability score. In the application research conducted on mobile stores, we identified and rated 25 applications through MARS. The overall scores ranged from 1.93 to 3.92 for the IOS app and 1.73 to 4.25 for the Play Store app. The findings suggest that few apps meet satisfying quality, content, and functionality criteria for LBP self-management.

Assessing the accessibility and quality of mobile health applications for the treatment of obesity in the German healthcare market

Introduction

Overweight and obesity are among the most prevalent health problems worldwide leading to various diseases and having a significant impact on the healthcare system. In Germany, the prevalence of obesity among adults is 19%. Mobile health applications offer a new approach to treatment and prevention and have been proven effective in previous studies. However, it is essential to investigate the availability and quality of these digital applications. The aim of this systematic assessment is to evaluate the accessibility and quality of digital health applications in German language designed to treat obesity.

Methods

In January 2024, a systematic search for mobile health applications was conducted on both the Google Play Store and Apple App Store. Just those apps available in German for both iOS and Android were considered acceptable. The German Mobile Application Rating Scale (MARS-G) was used to assess the quality of the apps. The content of mobile health applications was evaluated using the guideline from the German Obesity Society for the treatment of obesity. The characteristics of the apps were summarized and presented, and the results were analyzed using descriptive statistics and presented in tables.

Results

After screening, ten apps were included in the review. The apps varied in terms of calorie tracking, individual workout plans, educational aspects, nutritional plans, and exercises for behavioral change. On average, 6.4 out of 12 items of the German Obesity guideline recommendations were fulfilled. The MARS score (possible range from 1-5) reached a mean of 3.39 (SD = 0.39). The section "Engagement" had the lowest quality score with a mean of 3.14 (SD = 0.57), while the section "Aesthetics" achieved the highest mean of 3.57 (SD = 0.52).

Discussion

Most German mobile health applications for managing obesity meet some guideline recommendations. They demonstrate adequate to good quality according to the MARS score. Assessing the quality of mobile health applications can be challenging for patients, despite being easily accessible and low-threshold. However, such digital health applications, reimbursed by the German SHI, offer evidence-based information, even if access can be associated with higher hurdles.

Factors influencing the use of an artificial intelligence-based app (selfBACK) for tailored self-management support among adults with neck and/or low back pain

PURPOSE

Tailored self-management support is recommended as first-line treatment for neck and low back pain, for which mHealth applications could be promising. However, there is limited knowledge about factors influencing the engagement with such apps. The aim of this study was to assess barriers and facilitators for engaging with a self-management mHealth app among adults suffering from neck and/or low back pain.

MATERIALS AND METHODS

We carried out a qualitative descriptive study among adults with neck and/or low back pain. The artificial intelligence-based selfBACK app supports tailored self-management of neck and low back pain and was used for 6 weeks. After these 6 weeks, participants were interviewed by phone.

RESULTS

Thirty-two adults (17 males) with neck and/or low back pain participated (mean age = 54.9 (SD = 15.8)). Our results show that the mode of delivery and the novelty of the selfBACK app were perceived most often as a barrier to use the app. The action plans of the app and health-related factors were perceived most often as facilitating factors.

CONCLUSIONS

This study provides insight into possible strategies to improve an mHealth service. Furthermore, it shows that adults with neck and/or low back pain are willing and ready to receive blended treatment.

Inpatient pain assessment and decision-making in internal medicine and general surgery residents: A qualitative analysis

Background

Understanding physician approaches to pain treatment is a critical component of opioid and analgesic stewardship. Practice patterns learned in residency often persist longitudinally into practice.

Objective

This study sought to identify salient factors and themes in how resident physicians assess and manage pain.

Methods

Video-recorded focus groups of internal medicine and general surgery residents were conducted via videoconferencing software. Data were analyzed using a ground theory approach and constant comparative method to identify themes and subthemes. Focus groups occurred in September and October 2020.

Results

10 focus groups including 35 subjects were conducted. Four general themes emerged: (1) Assessment considerations; (2) Education & Expectations; (3) Systems Factors; and (4) Management considerations. Participants indicated that while it is important to treat pain, its inherently subjective nature makes it difficult to objectively quantify it. The 0-10 numeric rating scale was problematic and infrequently utilized. Patient expectations of no pain following procedures was viewed as particularly challenging. The absence of formal best practices to guide pain assessment and management was noted in every group. Management approaches overall very highly variable, often relying on word-of-mouth relay of the preferences of specific attending physicians.

Conclusions

Pain is highly nuanced and resident physicians struggle to balance pain's subjectivity with a desire to quantify and appropriately treat it. The 0-10 numeric rating pain scale, though ubiquitous, is problematic. Priority areas of improvement identified include education for both patients and physicians, functional pain scales, and expansion of existing effective resources like the nursing pain team.

Facilitators of and Barriers to the Use of a Digital Self-Management Service for Diagnostic Testing: Focus Group Study With Potential Users

BACKGROUND

Health care lags in digital transformation, despite the potential of technology to improve the well-being of individuals. The COVID-19 pandemic has accelerated the uptake of technology in health care and increased individuals' willingness to perform self-management using technology. A web-based service, Directlab Online, provides consumers with direct digital access to diagnostic test packages, which can digitally support the self-management of health.

OBJECTIVE

This study aims to identify the facilitators, barriers, and needs of Directlab Online, a self-management service for web-based access to diagnostic testing.

METHODS

A qualitative method was used from a potential user's perspective. The needs and future needs for, facilitators of, and barriers to the use of Directlab Online were evaluated. Semistructured focus group meetings were conducted in 2022. Two focus groups were focused on sexually transmitted infection test packages and 2 were focused on prevention test packages. Data analysis was performed according to the principles of the Framework Method. The Consolidated Framework for Implementation Research was used to categorize the facilitators and barriers.

RESULTS

In total, 19 participants, with a mean age of 34.32 (SD 14.70) years, participated in the focus groups. Important barriers were a lack of privacy information, too much and difficult information, and a commercial appearance. Important facilitators were the right amount of information, the right kind of tests, and the involvement of a health care professional. The need for a service such as Directlab Online was to ensure its availability for users' health and to maintain their health.

CONCLUSIONS

According to the participants, facilitators and barriers were comprehension of the information, the goal of the website, and the overall appearance of the service. Although the service was developed in cocreation with health care professionals and users, the needs did not align. The users preferred understandable and adequate, but not excessive, information. In addition, they preferred other types of tests to be available on the service. For future research, it would be beneficial to focus on cocreation between the involved medical professionals and users to develop, improve, and implement a service such as Directlab Online.

Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background

Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development.

Methods

We searched PubMed, PEDro and Embase for articles published in English up to May 3 rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies.

Results

We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use.

Conclusions

This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.

Digital Apps to Improve Mobility in Adults with Neurological Conditions: A Health App-Focused Systematic Review

The provision of mobility exercises through a smartphone application (app) for people undertaking neurological rehabilitation may improve mobility outcomes. However, it is difficult for clinicians and consumers to select high-quality, appropriate apps. This review aimed to identify (1) which mobile health (mHealth) apps are suitable for prescribing mobility exercises for adults with neurological health conditions, (2) how well these apps incorporate telehealth strategies, and (3) how well these apps rate in terms of quality and capacity for behaviour change. The Australian Apple iTunes Store was systematically searched, by using a search code and manually, for apps suitable for training mobility in neurological rehabilitation. Additional searches were conducted in known app repositories and for web-based apps. Trained reviewers extracted data from the included apps, including population-specific characteristics; quality, by using the Mobile App Rating Scale (MARS); and behaviour change potential, by using the App Behaviour Change Scale (ABACUS). The included apps (n = 18) provided <50 to >10,000 exercises, many incurred a subscription fee (n = 13), and half included telehealth features. App quality was moderate (mean MARS score of 3.2/5 and SD of 0.5), and potential for behaviour change was poor (mean ABACUS score of 5.7/21 and SD of 2.1). A limited number of high-quality apps are available for the prescription of mobility exercises in people with neurological conditions.

Addressing post-COVID-19 musculoskeletal symptoms through pulmonary rehabilitation and telemedicine: A study protocol

OBJECTIVE

The purpose of the study will be to evaluate the effect of pulmonary rehabilitation on the improvement of patients with post-COVID-19 musculoskeletal symptoms, as well as to quantify the impact of telemedicine that evaluates the evolution of pain, functionality, and quality of life.

METHODS

We will carry out a case-control study in post-COVID-19 musculoskeletal symptoms patients who will undergo pulmonary rehabilitation, together with an intervention and a follow-up using programmed telemedicine sessions. Data will be collected on the improvement of functional capacity and quality of life, in addition to assessing the evolution of musculoskeletal symptomatology, as well as pain and psychological variables. The approaches of face-to-face rehabilitation and telerehabilitation will also be compared. The telemedicine sessions will improve user adherence and follow-up, and the results are expected to be disseminated to the scientific community during and after the end of the study.

Addressing post-COVID-19 musculoskeletal symptoms through pulmonary rehabilitation and telemedicine: A study protocol

Objective

The purpose of the study will be to evaluate the effect of pulmonary rehabilitation on the improvement of patients with post-COVID-19 musculoskeletal symptoms, as well as to quantify the impact of telemedicine that evaluates the evolution of pain, functionality, and quality of life.

Methods

We will carry out a case-control study in post-COVID-19 musculoskeletal symptoms patients who will undergo pulmonary rehabilitation, together with an intervention and a follow-up using programmed telemedicine sessions. Data will be collected on the improvement of functional capacity and quality of life, in addition to assessing the evolution of musculoskeletal symptomatology, as well as pain and psychological variables. The approaches of face-to-face rehabilitation and telerehabilitation will also be compared. The telemedicine sessions will improve user adherence and follow-up, and the results are expected to be disseminated to the scientific community during and after the end of the study.

Evaluation of Patient-Facing Mobile Apps to Support Physiotherapy Care: Systematic Review

BACKGROUND

Mobile health interventions delivered through mobile apps are increasingly used in physiotherapy care. This may be because of the potential of apps to facilitate changes in behavior, which is central to the aims of care delivered by physiotherapists. A benefit of using apps is their ability to incorporate behavior change techniques (BCTs) that can optimize the effectiveness of physiotherapeutic interventions. Research continues to suggest that despite their importance, behavior change strategies are often missing in patient management. Evaluating mobile apps that physiotherapists can use to drive behavior change may inform clinical practice and potentially improve patient outcomes. Examining the quality of apps and exploring their key features that can support behavior change and physiotherapy care are important aspects of such an evaluation.

OBJECTIVE

The primary aim of this study was to describe the range of mobile apps in app stores that are intended for use by patients to support physiotherapy care. The secondary aims were to assess app quality, BCTs, and their behavior change potential.

METHODS

A systematic review of mobile apps in app stores was undertaken. The Apple App Store and Google Play were searched using a 2-step search strategy, using terms relevant to the physiotherapy discipline. Strict inclusion and exclusion criteria were applied: apps had to be intended for use by patients and be self-contained (or stand-alone) without the requirement to be used in conjunction with a partner wearable device or another plugin. Included apps were coded for BCTs using the Behavior Change Technique Taxonomy version 1. App quality was assessed using the Mobile App Rating Scale, and the App Behavior Change Scale was used to assess the app's potential to change behavior.

RESULTS

In total, 1240 apps were screened, and 35 were included. Of these 35 apps, 22 (63%) were available on both the Apple App Store and Google Play platforms. In total, 24 (69%) were general in their focus (eg, not condition-specific), with the remaining 11 (31%) being more specific (eg, knee rehabilitation and pelvic floor training). The mean app quality score (Mobile App Rating Scale) was 3.7 (SD 0.4) of 5 (range 2.8-4.5). The mean number of BCTs identified per app was 8.5 (SD 3.6). BCTs most frequently included in the apps were instruction on how to perform a behavior (n=32), action planning (n=30), and self-monitoring of behavior (n=28). The mean behavior change potential score (App Behavior Change Scale) was 8.5 (SD 3.1) of 21 (range 3-15).

CONCLUSIONS

Mobile apps available to support patient care received from a physiotherapist are of variable quality. Although they contain some BCTs, the potential for behavior change varied widely across apps.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/29047.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Physical activity advice given by French general practitioners for low back pain and the role of digital e-health applications: a qualitative study

BACKGROUND

Low back pain is the fourth most common reason for consulting a general practitioner (GP) among people aged 40-50 years. Beyond the overall benefits of physical activity (PA) on health (psychological, cardiovascular, etc.), PA for low back pain seems to improve the prognosis in terms of pain, disability, and quality of life. The French National Health Insurance developed media campaigns to promote physical activity with low back pain and a smartphone application (app). Despite the known benefits and campaigns, GPs do not routinely provide advice about physical activity during low back pain consultations. To promote giving physical activity advice for low back pain, there is a need to understand how GPs currently provide this advice and whether technology could help. This study aims to explore the content of physical activity advice for low back pain that GPs provide in France, and their opinion about healthcare smartphone app provided electronically via the internet (e-health apps) as a support for this advice.

METHODS

This qualitative study was conducted with semi-structured individual interviews among French GPs. The verbatim was double coded using a coding tree. Thematic analysis was performed using an inductive approach.

RESULTS

Sixteen GPs from Maine et Loire, Sarthe, and Mayenne were included. The thematic analysis identified the following themes: GPs use a global patient-centred approach to physical activity advice for low back pain. The main goal is to enable patients to participate in their care. Advice was almost always general with little information about duration and frequency. The importance of patient-appropriate and easily achievable activities was emphasised. GPs referred patients to physiotherapists to reinforce regular physical activity, maintain motivation and improve patient adherence through supervision and follow-up. GPs knew little about e-health apps but felt they could be useful with young patients. The main barriers to their use included poor internet connection, lack of technical knowledge and no supervision meaning patients could injure themselves.

CONCLUSIONS

This is one of the first studies to assess the contents of physical activity advice GPs provide for low back pain. Further research is needed into the implementation of e-health apps for low back pain management.

TRIAL REGISTRATION

Not applicable.

The Added Value of Face-to-Face Supervision to a Therapeutic Exercise-Based App in the Management of Patients with Chronic Low Back Pain: A Randomized Clinical Trial

Low back pain (LBP) is a significant global health challenge due to its high prevalence, and chronicity and recurrence rates, with projections suggesting an increase in the next years due to population growth and aging. The chronic and recurrent nature of LBP, responsible for a significant percentage of years lived with disability, underscores the need for effective management strategies, including self-management strategies advocated by current guidelines, to empower patients and potentially improve healthcare efficiency and clinical outcomes. Therefore, the aim of this study was to analyze the added value of face-to-face visits in patients with chronic LBP undergoing a self-management program based on therapeutic exercises on pain intensity, disability, quality of life and treatment adherence and satisfaction. A randomized clinical trial was conducted, allocating 49 patients into a experimental group with a mobile health (mHealth) app usage and face-to-face sessions and 49 patients into an active control group without face-to-face sessions. Pain intensity, disability and quality of life were assessed at baseline, 4 weeks postintervention and 12 weeks postintervention. Patients' satisfaction and adherence were assessed at the end of the study. The multivariate general model revealed no statistically significant time × group interaction for any outcome (p > 0.0068) but mental quality of life (p = 0.006). Within-group differences revealed significant improvements for all the clinical indicators (all, p < 0.001). Patients allocated to the experimental group reported greater satisfaction and adherence (both, p < 0.001) compared to the control group. The use of mHealth apps such as Healthy Back® as part of digital health initiatives may serve as a beneficial approach to enhance the management of LBP.

Physiotherapists' awareness and use of red flags for the assessment of low back pain in Saudi Arabia

BACKGROUND

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk.

OBJECTIVES

This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags.

METHODS

This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment.

RESULTS

A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags.

CONCLUSION

The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

The Effectiveness of Strategies to Improve User Engagement With Digital Health Interventions Targeting Nutrition, Physical Activity, and Overweight and Obesity: Systematic Review and Meta-Analysis

BACKGROUND

Digital health interventions (DHIs) are effective in improving poor nutrition, physical inactivity, overweight and obesity. There is evidence suggesting that the impact of DHIs may be enhanced by improving user engagement. However, little is known about the overall effectiveness of strategies on engagement with DHIs.

OBJECTIVE

This study aims to assess the overall effectiveness of strategies to improve engagement with DHIs targeting nutrition, physical activity, and overweight or obesity and explore associations between strategies and engagement outcomes. The secondary aim was to explore the impact of these strategies on health risk outcomes.

METHODS

The MEDLINE, Embase, PsycINFO, CINAHL, CENTRAL, Scopus, and Academic Source Complete databases were searched up to July 24, 2023. Eligible studies were randomized controlled trials that evaluated strategies to improve engagement with DHIs and reported on outcomes related to DHI engagement (use or user experience). Strategies were classified according to behavior change techniques (BCTs) and design features (eg, supplementary emails). Multiple-variable meta-analyses of the primary outcomes (usage and user experience) were undertaken to assess the overall effectiveness of strategies. Meta-regressions were conducted to assess associations between strategies and use and user experience outcomes. Synthesis of secondary outcomes followed the "Synthesis Without Meta-Analysis" guidelines. The methodological quality and evidence was assessed using the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment, Development, and Evaluation tool respectively.

RESULTS

Overall, 54 studies (across 62 publications) were included. Pooled analysis found very low-certainty evidence of a small-to-moderate positive effect of the use of strategies to improve DHI use (standardized mean difference=0.33, 95% CI 0.20-0.46; P<.001) and very low-certainty evidence of a small-to-moderate positive effect on user experience (standardized mean difference=0.29, 95% CI 0.07-0.52; P=.01). A significant positive association was found between the BCTs social support (effect size [ES]=0.40, 95% CI 0.14-0.66; P<.001) and shaping knowledge (ES=0.39, 95% CI 0.03-0.74; P=.03) and DHI use. A significant positive association was found among the BCTs social support (ES=0.70, 95% CI 0.18-1.22; P=.01), repetition and substitution (ES=0.29, 95% CI 0.05-0.53; P=.03), and natural consequences (ES=0.29, 95% CI 0.05-0.53; P=.02); the design features email (ES=0.29, 95% CI 0.05-0.53; P=.02) and SMS text messages (ES=0.34, 95% CI 0.11-0.57; P=.01); and DHI user experience. For secondary outcomes, 47% (7/15) of nutrition-related, 73% (24/33) of physical activity-related, and 41% (14/34) of overweight- and obesity-related outcomes reported an improvement in health outcomes.

CONCLUSIONS

Although findings suggest that the use of strategies may improve engagement with DHIs targeting such health outcomes, the true effect is unknown because of the low quality of evidence. Future research exploring whether specific forms of social support, repetition and substitution, natural consequences, emails, and SMS text messages have a greater impact on DHI engagement is warranted.

TRIAL REGISTRATION

PROSPERO CRD42018077333; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=77333.

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

Objective

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

Method

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

Results

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

Conclusion

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

Innovation

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

Mobile technologies for rehabilitation in non-specific spinal disorders: a systematic review of the efficacy and potential for implementation in low- and middle-income countries

PURPOSE

The aim of this systematic review was primarily to identify the types of mHealth technologies for the rehabilitation of non-specific spinal disorders, second to evaluate their efficacy, and finally to determine their applicability in LMICs.

METHODS

Three databases (Scopus, PubMed, and Web of Science) were searched for randomized controlled trials and clinical trials from January 2012 until December 2022. Studies were found eligible when using mHealth technologies for the rehabilitation of non-specific spinal disorders. To evaluate efficacy, the primary outcome was pain intensity, and the secondary outcomes were disability and quality of life. To evaluate the applicability in LMICs, information about financial and geographical accessibility, offline usability, and languages was extracted.

RESULTS

Fifteen studies were included comprising 1828 participants who suffer from non-specific low back pain (86.05%) and non-specific neck pain (13.95%). Fourteen distinct smartphone-based interventions and two sensor system interventions were found, with a duration ranging from four weeks to six months. All mHealth interventions demonstrated efficacy for the improvement of pain, disability and quality of life in non-specific spinal disorders, particularly low back pain. Five of the evaluated smartphone applications were free of charge accessible and had language features that could be adapted for use in LMICs.

CONCLUSION

mHealth interventions can be used and integrated into the conventional treatment of non-specific spinal disorders in rehabilitation. They have demonstrated efficacy and could be implemented in LMICs with minor adaptations to overcome language barriers and the absolute necessity of the internet.

Evaluation of Exercise Mobile Applications for Adults with Cardiovascular Disease Risk Factors

OBJECTIVE

To conduct a systematic review to determine if there are exercise mobile applications (apps) that can produce evidence-based, individualized exercise plans.

MATERIALS AND METHODS

We searched the Apple Store and Google Play for exercise apps with terms related to exercise and health. Exercise apps were eligible if they: (1) had a ≥4 out of 5 overall rating with ≥1000 reviews; (2) were free to download; and (3) were not gender specific. Exercise apps were evaluated via the evidence-based exercise prescription (ExRx) standards of the American College of Sports Medicine (ACSM) and American Heart Association. For the exercise app evaluation criteria, an app was included if it (1) was evidence-based; (2) contained a preparticipation health screening protocol; (3) built a cardiovascular disease (CVD) risk factor profile; (4) prioritized one chronic disease or health condition to focus on; (5) framed the exercise plan by the frequency, intensity, time, and type principle (FITT) of ExRx; and (6) specified special considerations.

RESULTS

Of the 531 potentially qualifying apps, 219 qualified. The qualifying apps were rarely evidenced-based (0.5%) or had a preparticipation screening protocol (3.7%). Only 27.7% built CVD risk factor profiles. Most apps (64.8%) focused on body image and/or athletic performance. Only 4.3% focused on chronic diseases or health conditions, while the remainder (34.5%) did not disclose a focus. No app framed the exercise plans by the FITT of ExRx. Only 1.4% of the apps specified special considerations.

CONCLUSION

There are no commercially available exercise apps that generate an evidence-based, individualized exercise plan for adults with CVD risk factors.

Efficacy of mHealth Interventions for Improving the Pain and Disability of Individuals With Chronic Low Back Pain: Systematic Review and Meta-Analysis

Background

Low back pain is one of the main causes of disability worldwide. Individuals with chronic conditions have been widely affected by the COVID-19 pandemic. In this context, mobile health (mHealth) has become popular, mostly due to the widespread use of smartphones. Despite the considerable number of apps for low back pain available in app stores, the effectiveness of these technologies is not established, and there is a lack of evidence regarding the effectiveness of the isolated use of mobile apps in the self-management of low back pain.

Objective

We summarized the evidence on the effectiveness of mHealth interventions on pain and disability for individuals with chronic low back pain.

Methods

We conducted a systematic review and meta-analysis comparing mHealth to usual care or no intervention. The search terms used were related to low back pain and mHealth. Only randomized controlled trials were included. The primary outcomes were pain intensity and disability, and the secondary outcome was quality of life. Searches were carried out in the following databases, without date or language restriction: PubMed, Scopus, Embase, Physiotherapy Evidence Database (PEDro), the Cochrane Library, and OpenGrey, in addition to article references. The risk of bias was analyzed using the PEDro scale. Data were summarized descriptively and through meta-analysis (pain intensity and disability). In the meta-analysis, eligible studies were combined while considering clinical and methodological homogeneity. The certainty of evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) criteria.

Results

A total of 5 randomized controlled trials were included, totaling 894 participants (447 allocated to the mHealth group and 445 to the usual care group), and they had similar methodological structure and interventions. Follow-up ranged from 6 weeks to 12 months. The studies did not demonstrate significant differences for pain intensity (mean difference -0.86, 95% CI -2.29 to 0.58; P=.15) and disability (standardized mean difference -0.24, 95% CI -0.69 to 0.20; P=.14) when comparing mHealth and usual care. All studies showed biases, with emphasis on nonconcealed allocation and nonblinding of the outcome evaluator. The certainty of evidence was rated as low for the analyzed outcomes.

Conclusions

mHealth alone was no more effective than usual care or no treatment in improving pain intensity and disability in individuals with low back pain. Due to the biases found and the low certainty of evidence, the evidence remains inconclusive, and future quality clinical trials are needed.

Availability, Quality, and Evidence-Based Content of mHealth Apps for the Treatment of Nonspecific Low Back Pain in the German Language: Systematic Assessment

BACKGROUND

Nonspecific low back pain (NSLBP) carries significant socioeconomic relevance and leads to substantial difficulties for those who are affected by it. The effectiveness of app-based treatments has been confirmed, and clinicians are recommended to use such interventions. As 88.8% of the German population uses smartphones, apps could support therapy. The available apps in mobile app stores are poorly regulated, and their quality can vary. Overviews of the availability and quality of mobile apps for Australia, Great Britain, and Spain have been compiled, but this has not yet been done for Germany.

OBJECTIVE

We aimed to provide an overview of the availability and content-related quality of apps for the treatment of NSLBP in the German language.

METHODS

A systematic search for apps on iOS and Android was conducted on July 6, 2022, in the Apple App Store and Google Play Store. The inclusion and exclusion criteria were defined before the search. Apps in the German language that were available in both stores were eligible. To check for evidence, the apps found were assessed using checklists based on the German national guideline for NSLBP and the British equivalent of the National Institute for Health and Care Excellence. The quality of the apps was measured using the Mobile Application Rating Scale. To control potential inaccuracies, a second reviewer resurveyed the outcomes for 30% (3/8) of the apps and checked the inclusion and exclusion criteria for these apps. The outcomes, measured using the assessment tools, are presented in tables with descriptive statistics. Furthermore, the characteristics of the included apps were summarized.

RESULTS

In total, 8 apps were included for assessment. Features provided with different frequencies were exercise tracking of prefabricated or adaptable workout programs, educational aspects, artificial intelligence-based therapy or workout programs, and motion detection. All apps met some recommendations by the German national guideline and used forms of exercises as recommended by the National Institute for Health and Care Excellence guideline. The mean value of items rated as "Yes" was 5.75 (SD 2.71) out of 16. The best-rated app received an answer of "Yes" for 11 items. The mean Mobile Application Rating Scale quality score was 3.61 (SD 0.55). The highest mean score was obtained in "Section B-Functionality" (mean 3.81, SD 0.54).

CONCLUSIONS

Available apps in the German language meet guideline recommendations and are mostly of acceptable or good quality. Their use as a therapy supplement could help promote the implementation of home-based exercise protocols. A new assessment tool to obtain ratings on apps for the treatment of NSLBP, combining aspects of quality and evidence-based best practices, could be useful.

TRIAL REGISTRATION

Open Science Framework Registries sq435; https://osf.io/sq435.

Content and Quality of Mobile Apps for the Monitoring of Musculoskeletal or Neuropathic Pain in Australia: Systematic Evaluation

Background

Mobile apps offer a potential mechanism for people with persistent pain to monitor pain levels conveniently within their own environment and for clinicians to remotely monitor their patients' pain. However, the quality of currently available apps and the usefulness of included features from a clinical perspective are not known.

Objective

The aim of this study was to examine the content and quality of currently available smartphone apps designed for monitoring the intensity or presence of musculoskeletal or neuropathic pain.

Methods

A systematic search was performed in the Australian Apple and Google Play stores. Apps were included if they were designed to monitor the intensity or presence of musculoskeletal or neuropathic pain and were available in the English language within the Australian app stores. Data pertaining to the intended use of the app and clinical population were extracted by using a custom-designed data extraction form, and app quality was assessed by using the 23-item Mobile App Rating Scale.

Results

Of the 2190 apps screened, 49 met the inclusion criteria. Apps were primarily designed for adult users (36/49, 73%) with nonspecific musculoskeletal or neuropathic pain conditions, arthritis, and joint pain. All apps monitored pain intensity, with almost half (23/49, 47%) also specifying pain location. Overall, the mean quality scores from the Mobile App Rating Scale ranged from 1.5 to 4.4 (out of 5.0). Between 20% (10/49) and 22% (11/49) of apps involved clinicians, consumers, or both in their development, and 20% (10/49) had published literature related to the development or use of the app in clinical scenarios. Although 71% (35/49) had data sharing features, only 5 apps enabled client-clinician communication through the app.

Conclusions

The overall quality of mobile apps that are currently available for monitoring pain intensity is acceptable. Presently, mobile apps for remote pain monitoring lack functionality for clinicians to view data between consults. Both users and clinicians should be aware of the limitations of these apps and make informed choices in using or recommending apps that best suit the clinical need.

Mobile applications for cognitive training: Content analysis and quality review

Background

As the number of individuals suffering from cognitive diseases continues to rise, dealing with the diminished cognitive function that comes with age has become a serious public health concern. While the use of mobile applications (apps) as digital treatments for cognitive training shows promise, the analysis of their content and quality remains unclear.

Objective

The aim of this study was to systematically search and assess cognitive training apps using the multidimensional mobile app rating scale (MARS) to rate objective quality and identify critical points.

Methods

A search was conducted on the Google Play Store and Apple App Store in February 2022 using the terms "cognitive training" and "cognitive rehabilitation." The cognitive domains provided by each app were analyzed, and the frequency and percentage according to the apps were obtained. The MARS, a mHealth app quality rating tool including multidimensional measures, was used to analyze the quality of the apps. The relationship between the MARS score, the number of reviews, and 5-star ratings were examined.

Results

Of the 53 apps, 52 (98 %) included memory function, 48 (91 %) included attention function, 24 (45 %) included executive function, and 19 (36 %) included visuospatial function. The mean (SD) scores of MARS, 5-star ratings, and reviews of 53 apps were 3.09 (0.61), 4.33 (0.30), and 62,415.43 (121,578.77). From the between-section comparison, engagement (mean 2.97, SD 0.68) obtained lower scores than functionality (mean 3.18, SD 0.62), aesthetics (mean 3.13, SD 0.72), and information (mean 3.11, SD 0.54). The mean quality score and reviews showed a statistically significant association (r = 0.447 and P = .001*). As the number of domains increased, the mean quality score showed a statistically significant increasing trend (P = .002*).

Conclusions

Most apps provided training for the memory and attention domains, but few apps included executive function or visuospatial domains. The quality of the apps improved significantly when more domains were provided, and was positively associated with the number of reviews received. These results could be useful for the future development of mobile apps for cognitive training.

Psychologically Informed Practice: The Importance of Communication in Clinical Implementation

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician-patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions.

Exploring mHealth applications for self-management of chronic low back pain: A survey of features and benefits

The adoption of Mobile Health (mHealth) for self-management is growing. mHealth solutions are commonly used in public healthcare and health services, where they are appreciated for their ease of use, broad reach, and wide acceptance. Chronic Low Back Pain (CLBP) is one of the most common health problems and a leading cause of disability. As such, it imposes a tremendous burden on patients and society. Studies have proposed that mHealth self-management solutions, such as mobile applications, can supplement traditional care methods and benefit patients, particularly in self-managing CLBP easier. To this end, the number of available mobile applications for CLBP has increased. This paper i) provides an overview of scientific studies on mobile applications for CLBP management from three different viewpoints: researchers, health professionals, and patients, ii) uncovers the application features that were seen as beneficial in the studies, and iii) contrasts the currently available applications for CLBP in Google Play Store and Apple App Store against the discovered features. The findings show that "Personalization and customization" is the most significant feature as it is beneficial from stakeholders' viewpoint and is represented by most applications. In contrast, "Gamification" and "Artificial intelligence" are the least significant features, indicating a lack of attention from application creators and researchers in this area.

A Review of Chronic Pain and Device Interventions: Benefits and Future Directions

Chronic pain is a debilitating condition with a growing prevalence both in the USA and globally. The complex nature of this condition necessitates a multimodal approach to pain management that extends beyond the established pharmaceutical interventions currently employed. A variety of devices comprising both invasive and noninvasive approaches are available to patients, serving as adjuvants to existing regimens. The benefits of these interventions are notable for their lack of addiction potential, potential for patient autonomy regarding self-administration, minimal to no drug interaction, and overall relative safety. However, there remains a need for further research and more robust clinical trials to assess the true efficacy of these interventions and elucidate if there is an underlying physiological mechanism to their benefit in treating chronic pain or if their effect is predominantly placebo in nature. Regardless, the field of device-based intervention and treatment remains an evolving field with much promise for the future chronic pain management.

DECENT: A sociotechnical approach for developing mobile health apps in underserved settings

Objective

Despite the fact that user engagement is critical to the efficacy of mobile health (mHealth) interventions in the Global South, many of these interventions lack user engagement features. This is because sociotechnical aspects of such initiatives are frequently ignored during the design, development, and implementation stages. This research highlighted the importance of considering sociotechnical factors when developing mHealth apps. The intended users for the mHealth technologies in this study are care professionals.

Materials and Methods

Five semi-structured interviews and a pilot interview were conducted to identify user engagement facilitators and barriers. The interview data were analysed using NVivo. The Capability, Opportunity, Motivation - Behaviour (COM-B) model is then used to map the facilitators and barriers to mHealth app engagement, allowing researchers to better understand how users engage/disengage with mHealth apps.

Results and Discussion

Capability facilitators included features that assist users in learning more about the app (e.g. a user manual and statistical data) as well as features that assist users in developing a routine. The lack of app skills and cognitive overload limit capability. While social connectedness and offline functionality were identified as facilitators of user engagement, non-user-friendly design and cultural dimensions were identified as barriers. Early user engagement and rewards were identified as motivational facilitators that influence user engagement. Furthermore, perceived non-utility and a lack of encouragement were identified as motivational barriers to engagement.

Conclusion

Several factors were discovered across all COM-B model components that could be used to develop more engaging mHealth apps. Adopting a techno-centric approach that ignores sociotechnical factors can reduce user engagement. The design process engagement enhancement system (DECENT) framework was proposed based on the findings.

Multimedia Instructions for Motor Control Exercises in Patients With Chronic Nonspecific Low Back Pain

BACKGROUND

Low back pain (LBP) is one of the top 3 diseases that may lead to disability. Current treatment guidelines define exercise as a first-line treatment for nonspecific LBP (NSLBP). There are various evidence-based exercise approaches for treating NSLBP, and many of them include motor control principles. Motor control exercises (MCEs) are better than general exercises that do not include motor control principles. Many patients find learning these exercises complex and challenging, in that MCE exercises have no standard teaching method. The researchers of this study developed multimedia instructions for an MCE program to make teaching MCE easier; thus, more effective.

METHODS

The participants were randomized into multimedia or standard (face-to-face) instruction groups. We applied the same treatments to both groups at the same dosage. The only differences between groups were the exercise instruction methods. The multimedia group learned MCE from multimedia videos; the control group learned MCE from a physiotherapist with face-to-face instructions. Treatment lasted 8 weeks. We evaluated patients' exercise adherence with Exercise Adherence Rating Scale (EARS), pain with the Visual Analog Scale, and disability with Oswestry Disability Index. Evaluations were made before and after treatment. Follow-up evaluations were carried out 4 weeks after the end of treatment.

RESULTS

There was no statistically significant interaction between the group and time on pain, F2,56 = 0.068, P = .935, partial η2 = .002 and Oswestry Disability Index scores, F2,56 = 0.951, P = .393, partial η2 = .033. Also, there was no statistically significant interaction between the group and time on Exercise Adherence Rating Scale total scores F1,20 = 2.343, P = .142, partial η2 = .105.

CONCLUSIONS

This study showed that multimedia instructions for MCE have similar effects to standard (face-to-face) instructions on pain, disability, and exercise adherence in patients with NSLBP. To our knowledge, with these results, the developed multimedia instructions became the first free, evidence-based instructions that have objective progression criteria and a Creative Commons license.

Impact of an AI app-based exercise program for people with low back pain compared to standard care: A longitudinal cohort-study

Background

Low Back Pain (LBP) is a common health problem worldwide. In recent years, the use of mobile applications for the treatment of various diseases has increased, due to the Corona pandemic.

Objective

The aim of this study is to investigate the extent to which artificial intelligence (AI)-assisted exercise recommendations can reduce pain and pain-related impairments in daily life for patients with LBP, compared to standard care.

Methods

To answer the research question, an 8-week app-based exercise program was conducted in the intervention group. To measure the influence of the exercise program, pain development and pain-related impairment in daily life have been evaluated. A so-called rehabilitation sports group served as the control group. The main factors for statistical analysis were factor time and group comparison. For statistical calculations, a mixed analysis of variance for pain development was conducted. A separate check for confounders was made. For pain impairment in daily life nonparametric tests with the mean of change between the time points are conducted.

Results

The intervention group showed a reduction in pain development of 1.4 points compared to an increase of 0.1 points in the control group on the numeric rating scale. There is a significant interaction of time and group for pain development. Regarding pain-related impairments in daily life, the intervention group has a reduction of the oswestry disability index scores by 3.8 points compared to an increase of 2.3 in the control group. The biggest differences become apparent 8 weeks after the start of treatment. The significant results have a medium to strong effect.

Conclusion

The results shown here suggest that the use of digital AI-based exercise recommendations in patients with LBP leads to pain reduction and a reduction in pain-related impairments in daily living compared to traditional group exercise therapy.

Effectiveness of smartphone apps for the self-management of low back pain in adults: a systematic review

PURPOSE

To explore the effectiveness of smartphone apps for the self-management of low back pain in adults.

METHODS

Prospectively registered systematic review of randomised controlled trials (2008-) published in English. Studies investigating smartphone apps for the self-management of low back pain (adults ≥18 years), including ≥1 NICE low back pain and sciatica clinical guideline-recommended component and functioning without health professional input were included. Outcomes were pain, function, quality of life and adherence.

RESULTS

Six studies were included (n = 2100 participants). All comparator groups incorporated some form of management (n = 3 physiotherapy, n = 2 GPs, n = 1 not specified). Three studies reported a significant decrease in pain intensity in the intervention group compared with the control. One study reported no significant difference between groups in pain self-efficacy. One study reported a significant reduction in disability (function) in the intervention group compared with the control. Two studies reported no between-group differences in quality of life. One study reported no correlation between adherence (app use) and change in pain intensity and one study reported that app use mediated the effect of teleconsultations on pain improvements.

CONCLUSIONS

Inconclusive evidence exists for the use of smartphone applications for the self-management of low back pain. Further research is needed.Implications for RehabilitationSmartphone apps have the potential to improve outcomes for people with LBP aligned with current self-management guidelines.There is a paucity of literature exploring smartphone apps for LBP self-management and current evidence is inconclusive for smartphone app use without supported care.Commercially available smartphone apps are not well regulated for content or alignment with evidence-based guidelines and recommendations.Further evaluation of commercially available apps is required to guide and instil confidence in consumers and health professionals that consumer-accessible apps may lead to improved outcomes.

Availability, content and quality of commercially available smartphone applications for the self-management of low back pain: a systematic assessment

PURPOSE

Explore smartphone apps that may be recommended by clinicians for the self-management of low back pain.

METHODS

Prospectively registered systematic assessment of self-contained apps for self-management of low back pain on the Google Play and Apple App stores (Oceania), including ≥1 NICE low back pain and sciatica clinical guideline-recommended component and functioning without health professional input. Outcomes were quality (Mobile App Rating Scale; MARS), and self-management (Self-Management Support Checklist; SMS-14) and behaviour change potential (App Behaviour Change Scale; ABACUS).

RESULTS

25 apps were included. The average quality of included apps was acceptable (Mean MARS score of 3.9 out of a maximum possible 5). The self-management support and behaviour change potential of included apps appeared low (mean SMS-14 score was 3.4/14; mean ABACUS score was 5.4/21). The apps showed no significant correlation between app consumer ratings and MARS scores. App quality was significantly correlated with app price (p = 0.049) but not consumer ratings, however, these findings were based on a small number of studies and the overall model was not significant.

CONCLUSIONS

Smartphone apps for the self-management of low back pain are of average to good quality, with questionable potential for self-management and behaviour change. Clinicians should consider that few apps were designed to specifically incorporate self-management support and behaviour change potential when recommending apps to clients. Further development in these areas of app design would be of benefit.Implications for RehabilitationSmartphone apps have the potential to improve LBP self-management outcomes, however, apps are not well regulated and the quality of information and advice provided is often low quality.The findings from this systematic assessment indicate that LBP self-management apps have limited self-management support and behaviour change potential features.Recommendation of current smartphone apps for LBP should take into consideration that although apps are of acceptable quality they are not specifically designed with self-management support and behaviour change principles.App quality does not appear to be associated with consumer ratings, however, there may be a positive association between app price and quality which requires further investigation.

Can you be a manual therapist without using your hands?

BACKGROUND

To align with current best practices, manual therapists have refined their treatment options to include exercise and pain education for people with chronic musculoskeletal pain. In this commentary, we suggest that manual therapists should also add telehealth to their toolbox. Thus, we aim to discuss the use of telehealth by manual therapists caring for patients with musculoskeletal disorders.

MAIN BODY

Telehealth can be delivered to the patient in different modes, such as real-time clinical contact or asynchronously. Platforms vary from websites and smartphone apps to virtual reality systems. Telehealth may be an effective approach, especially for improving pain and function in people with musculoskeletal pain, and it has the potential to reduce the individual and socioeconomic burden of musculoskeletal conditions. However, the certainty of evidence reported in systematic reviews is often low. Factors such as convenience, flexibility, undivided attention from the clinician, user-friendly platforms, goal setting, and use of evidence-based information are all enablers for telehealth use and improving patients' knowledge, self-efficacy, and self-management. Barriers to widening the use of telehealth in musculoskeletal care include the reliability of technology, data privacy issues, difficult to build therapeutic alliance, one-size-fits-all approaches, digital health literacy, and payment models.

CONCLUSION

We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Creating a Self-management Mobile Application for People With Chronic Low Back Pain: A Focus Group Study of Unmet Needs and Strategies

Mobile health can fulfill the unmet needs of patients with chronic low back pain by recommending individualized management plans. Limited mobile applications have been developed based on the needs, preferences, and values relative to self-management of patients with chronic low back pain. This study aimed to explore the experience of patients with chronic low back pain and the desired content, designs, and features of a self-management application. We conducted five focus groups (N = 24). Participants provided feedback on draft contents and they also discussed the desired designs and features of an application while reviewing a low-fidelity prototype. Data were audio-recorded, transcribed verbatim, and analyzed using qualitative content analysis. Three categories and eight subcategories emerged. Participants: (1) confronted difficulties of their pain experience along with vicious cycles of pain and unmet needs; (2) acknowledged the importance of self-management as they lived with chronic low back pain and realized how to self-manage their pain; and (3) suggested ways to fulfill needs and preferences among patients with chronic low back pain. The nature of chronic low back pain causes disruptions well-being and requires constant management. Developing user-centered strategies to enhance knowledge and promote self-management among chronic low back pain patients is required.

Mobile Apps for the Management of Gastrointestinal Diseases: Systematic Search and Evaluation Within App Stores

Background

Gastrointestinal diseases are associated with substantial cost in health care. In times of the COVID-19 pandemic and further digitalization of gastrointestinal tract health care, mobile health apps could complement routine health care. Many gastrointestinal health care apps are already available in the app stores, but the quality, data protection, and reliability often remain unclear.

Objective

This systematic review aimed to evaluate the quality characteristics as well as the privacy and security measures of mobile health apps for the management of gastrointestinal diseases.

Methods

A web crawler systematically searched for mobile health apps with a focus on gastrointestinal diseases. The identified mobile health apps were evaluated using the Mobile Application Rating Scale (MARS). Furthermore, app characteristics, data protection, and security measures were collected. Classic user star rating was correlated with overall mobile health app quality.

Results

The overall quality of the mobile health apps (N=109) was moderate (mean 2.90, SD 0.52; on a scale ranging from 1 to 5). The quality of the subscales ranged from low (mean 1.89, SD 0.66) to good (mean 4.08, SD 0.57). The security of data transfer was ensured only by 11 (10.1%) mobile health apps. None of the mobile health apps had an evidence base. The user star rating did not correlate with the MARS overall score or with the individual subdimensions of the MARS (all P>.05).

Conclusions

Mobile health apps might have a positive impact on diagnosis, therapy, and patient guidance in gastroenterology in the future. We conclude that, to date, data security and proof of efficacy are not yet given in currently available mobile health apps.

App-Based Rehabilitation in Back Pain, a Systematic Review

Smartphones and their associated applications are used frequently by patients and clinicians alike. Despite the technology being widely accessible, their use to aid in rehabilitation is yet to be adopted. The SARS CoV-2 pandemic has presented an opportunity to expedite their integration given the difficulty patients currently have in accessing healthcare. The aim of this study was to perform a systematic literature review on the use of smartphone rehabilitation applications compared to standard physiotherapy for back pain. We conducted a search of Medline/Pubmed and google databases using the search terms [APP] AND [[Orthopaedic] OR [Neurosurgery]], following the PRISMA guidelines. All prospective studies investigating rehabilitation applications for back pain or following spine surgery were included. A total of nine studies met the inclusion criteria which investigated 7636 patients, of which 92.4% were allocated to the interventional group (n = 7055/7636) with a follow up of 4 weeks to 6 months. All except one study reported on patients experiencing back pain on average for 19.6 ± 11.6 months. The VAS-pain score was presented in all studies without significance between the interventional and control group (p = 0.399 before and p = 0.277 after intervention). Only one research group found significantly higher improvement in PROMs for the application group, whereas the remaining showed similar results compared to the control group. Using application-based rehabilitation programs provides an easily accessible alternative or substitute to traditional physiotherapy for patients with back pain. Given that smartphones are so prevalent in activities in our daily lives, this will enhance and improve rehabilitation if patients are self-dedicated and compliant.

Exploratory application of machine learning methods on patient reported data in the development of supervised models for predicting outcomes

BACKGROUND

Patient-reported outcome measurements (PROMs) are commonly used in clinical practice to support clinical decision making. However, few studies have investigated machine learning methods for predicting PROMs outcomes and thereby support clinical decision making.

OBJECTIVE

This study investigates to what extent different machine learning methods, applied to two different PROMs datasets, can predict outcomes among patients with non-specific neck and/or low back pain.

METHODS

Using two datasets consisting of PROMs from (1) care-seeking low back pain patients in primary care who participated in a randomized controlled trial, and (2) patients with neck and/or low back pain referred to multidisciplinary biopsychosocial rehabilitation, we present data science methods for data prepossessing and evaluate selected regression and classification methods for predicting patient outcomes.

RESULTS

The results show that there is a potential for machine learning to predict and classify PROMs. The prediction models based on baseline measurements perform well, and the number of predictors can be reduced, which is an advantage for implementation in decision support scenarios. The classification task shows that the dataset does not contain all necessary predictors for the care type classification. Overall, the work presents generalizable machine learning pipelines that can be adapted to other PROMs datasets.

CONCLUSION

This study demonstrates the potential of PROMs in predicting short-term patient outcomes. Our results indicate that machine learning methods can be used to exploit the predictive value of PROMs and thereby support clinical decision making, given that the PROMs hold enough predictive power.

mHealth Apps for Low Back Pain Self-management: Scoping Review

Background

The role of self-management in health promotion, as well as prevention and rehabilitation, is increasing through the use of mobile health (mHealth) apps. Such mHealth apps are also increasingly being used for self-management of low back pain (LBP), but their effectiveness has not been sufficiently explored.

Objective

The aim of this scoping review was to provide an overview of the literature on self-management mHealth apps and their effects on the levels of pain and disability in people with LBP.

Methods

We applied the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology, including a priori research questions. A literature search was conducted in 2 databases (PubMed and PEDro) for studies published between January 1, 2015, and June 17, 2021. Interventional, cohort, or case series studies with an interventional period were included if the mHealth app included built-in self-management content, the app was used for self-management for people with LBP, and the study reported outcomes regarding pain and disability in people with LBP.

Results

In total, 7 studies were selected for the review with overall 2307 persons with LBP, of whom 1328 (57.56%) were women. Among the studies (5/7, 71%) that reported the type of pain, 85% (390/459) of the participants were experiencing chronic LBP. A total of 5 different mHealth apps were identified, of which 4 contributed to a statistically significant reduction in LBP and clinically meaningful changes. Of the 7 studies, 4 (57%) used 4 different assessments for disability, of which 3 (75%) showed statistically significant improvements in the level of functional ability of participants in the experimental groups using an mHealth app with built-in self-management content for LBP.

Conclusions

This scoping review supports the conclusion that people with LBP may benefit from mHealth apps that provide self-management content. However, the generalizability of the findings is limited because of heterogeneity in the pain characterization of the included participants and the intervention durations. More high-quality studies with longer follow-up periods to investigate personalized mHealth approaches are recommended for LBP self-management.

Mobile health technologies for the management of spine disorders: A systematic review of mHealth applications in Brazil

BACKGROUND

Spine disorders are conditions that affect a growing number of individuals, and mobile health (mHealth) applications (apps) offer potential to assist the self-management of these conditions.

OBJECTIVES

To perform a systematic review of the availability of mHealth apps for patients with spine disorders at Brazilian online stores and evaluate the apps in terms of engagement, user interface, experience, and quality of the information.

DESIGN

Systematic review.

METHOD

A search for spine disorders mHealth apps from the Google Play Store and AppStore in Brazil was performed by two independent reviewers on June 2021. Only smartphone apps in Brazilian Portuguese directed at spine disorders that provided information about education, counseling, exercise, or monitoring of patient health were included. The quality of eligible mHealth apps was assessed using the Mobile App Rating Scale (MARS).

RESULTS

Of the 2775 mHealth apps found, 10 were eligible for inclusion. All apps offered exercise programs. Three apps also offered tools to track patient-reported symptoms, nutritional orientation, or educational content in addition to the exercise program. Using MARS, the apps scored poorly in terms of quality, with an overall mean score ±standard deviation of 2.75 ± 0.63 on a scale of 1-5 points. Most apps scored poorly for credibility, user interface, and engagement.

CONCLUSIONS

The mHealth apps for spine disorders currently available in Brazil are of poor quality and limited functionality. Effective collaboration between industry and researchers is needed to develop better user-centered mHealth apps that can empower patients with these conditions.

Mobile application tool for remote rehabilitation after discharge from coronavirus disease-19 rehabilitation unit

A smartphone application (Medico-Amico) has been developed by the collaboration of San Raffaele Scientific Institute and Khymeia Group S.R.L. with the aim of providing physical exercises and communicating with patients after their hospitalization in a coronavirus disease (COVID)-rehabilitation unit. Thirty patients used the application for remote rehabilitation for 4 weeks. They were prescribed personalized motor exercises to perform three times a week. Clinicians could interact with each patient by an encrypted video call in order to give encouragement, mental support, modify intensity during training sessions, or to prescribe new exercises. Patients were asked to perform motor exercises and also to monitor their vital signs, such as temperature, blood pressure, and oxygen saturation, inserting scores in a specific section of the application. After 4 weeks of remote rehabilitation patients showed improvements in independence during activity of daily living and strength. Also, satisfaction and mobile application usability scores reached patients' appreciation and enjoyment.

What Constitutes "Appropriate Care" for Low Back Pain?: Point-of-Care Clinical Indicators From Guideline Evidence and Experts (the STANDING Collaboration Project)

STUDY DESIGN

Multiround wiki-based Delphi expert panel survey.

OBJECTIVE

To provide proof of concept for an alternative method for creating sets of nationally-agreed point-of-care clinical indicators, and obtain consensus among end-user groups on "appropriate care" for the assessment, diagnosis, acute, and ongoing care of people with low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The provision of inappropri ate and low value care for LBP is a significant healthcare and societal burden. Vague clinical practice guideline (CPG) recom mendations can be difficult to apply and measure in real world clinical practice, and a likely barrier to "appropriate care."

METHODS

Draft "appropriate care" clinical indicators for LBP were derived from CPG recommendations published between 2011 and 2017. Included CPGs were independently appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation instrument. Headed by a Clinical Champion, a 20-member Expert Panel reviewed and commented on the draft indicators over a three-round modified e-Delphi process using a collaborative online wiki. At the conclusion of each review round, the research team and the Clinical Champion synthesized and responded to experts' comments and incorporated feedback into the next iteration of the draft indicators.

RESULTS

From seven CPGs and six qualitative meta-syntheses, 299 recommendations and themes were used to draft 42 "appropriateness" indicators. In total, 17 experts reviewed these indicators over 18 months. A final set of 27 indicators compris ing screening and diagnostic processes (n = 8), assessment (n = 3), acute (n = 5), and ongoing care (n = 9), and two which crossed the acute-ongoing care continuum. Most indicators were geared toward recommended care (n = 21, 78%), with the remainder focused on care to be avoided.

CONCLUSION

These 27 LBP clinical indicators can be used by healthcare consumers, clinicians, researchers, policy makers/ funders, and insurers to guide and monitor the provision of "appropriate care" for LBP.Level of Evidence: 4.

Do pain management apps use evidence-based psychological components? A systematic review of app content and quality

Background

With hundreds of pain management apps on the Canadian marketplace, it can be challenging for patients and clinicians to select effective and evidence-based mobile health (mHealth) apps that address pain from a biopsychosocial perspective.

Aims

The aim of this study is to identify pain management apps within the Canadian app marketplaces to aid clinicians in recommending apps.

Methods

The iOS and Android marketplaces were systematically searched to identify pain management apps that included at least one core component of cognitive behavioral therapy (CBT) or mindfulness- and acceptance-based therapies. Selected apps were assessed using a researcher developed psychological components checklist, and the Mobile App Rating Scale (MARS). These two measures provided a robust assessment of the apps' technical abilities and psychological principles being implemented.

Results

Five hundred eight pain management apps were identified, yet only 12 included a psychological component and were available for evaluation. On average, apps contained 8.10 out of 18 psychological components (SD = 2.77) with a MARS quality rating of 4.02 out of 5 (SD = 0.32). The most common psychological components were grounded in CBT, including psychoeducation, sleep hygiene, behavioral activation, coping skills training, and social support. Among the least commonly included components were goal setting, values, and culture/diversity. Two-thirds of the apps involved health care practitioners in their development, but independent scientific review of apps was scarce.

Conclusion

The highest scoring apps (Curable, Pathways, Vivify) are highlighted for health care practitioners who may wish to recommend mHealth technologies to their patients for pain management. Future directions for research and app development are discussed.

Smartphones for musculoskeletal research - hype or hope? Lessons from a decennium of mHealth studies

BACKGROUND

Smartphones provide opportunities for musculoskeletal research: they are integrated in participants' daily lives and can be used to collect patient-reported outcomes as well as sensor data from large groups of people. As the field of research with smartphones and smartwatches matures, it has transpired that some of the advantages of this modern technology are in fact double-edged swords. BODY: In this narrative review, we illustrate the advantages of using smartphones for data collection with 18 studies from various musculoskeletal domains. We critically appraised existing literature, debunking some myths around the advantages of smartphones: the myth that smartphone studies automatically enable high engagement, that they reach more representative samples, that they cost little, and that sensor data is objective. We provide a nuanced view of evidence in these areas and discuss strategies to increase engagement, to reach representative samples, to reduce costs and to avoid potential sources of subjectivity in analysing sensor data.

CONCLUSION

If smartphone studies are designed without awareness of the challenges inherent to smartphone use, they may fail or may provide biased results. Keeping participants of smartphone studies engaged longitudinally is a major challenge. Based on prior research, we provide 6 actions by researchers to increase engagement. Smartphone studies often have participants that are younger, have higher incomes and high digital literacy. We provide advice for reaching more representative participant groups, and for ensuring that study conclusions are not plagued by bias resulting from unrepresentative sampling. Costs associated with app development and testing, data storage and analysis, and tech support are substantial, even if studies use a 'bring your own device'-policy. Exchange of information on costs, collective app development and usage of open-source tools would help the musculoskeletal community reduce costs of smartphone studies. In general, transparency and wider adoption of best practices would help bringing smartphone studies to the next level. Then, the community can focus on specific challenges of smartphones in musculoskeletal contexts, such as symptom-related barriers to using smartphones for research, validating algorithms in patient populations with reduced functional ability, digitising validated questionnaires, and methods to reliably quantify pain, quality of life and fatigue.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

NCT05058547.

An Educational and Exercise Mobile Phone–Based Intervention to Elicit Electrophysiological Changes and to Improve Psychological Functioning in Adults With Nonspecific Chronic Low Back Pain (BackFit App): Nonrandomized Clinical Trial

Background

Concomitant psychological and cognitive impairments modulate nociceptive processing and contribute to chronic low back pain (CLBP) maintenance, poorly correlated with radiological findings. Clinical practice guidelines recommend self-management and multidisciplinary educational and exercise-based interventions. However, these recommendations are based on self-reported measurements, which lack evidence of related electrophysiological changes. Furthermore, current mobile health (mHealth) tools for self-management are of low quality and scarce evidence. Thus, it is necessary to increase knowledge on mHealth and electrophysiological changes elicited by current evidence-based interventions.

Objective

The aim of this study is to investigate changes elicited by a self-managed educational and exercise-based 4-week mHealth intervention (BackFit app) in electroencephalographic and electrocardiographic activity, pressure pain thresholds (PPTs), pain, disability, and psychological and cognitive functioning in CLBP versus the same intervention in a face-to-face modality.

Methods

A 2-arm parallel nonrandomized clinical trial was conducted at the University of the Balearic Islands (Palma, Spain). A total of 50 patients with nonspecific CLBP were assigned to a self-managed group (23/50, 46%; mean age 45.00, SD 9.13 years; 10/23, 43% men) or a face-to-face group (27/50, 54%; mean age 48.63, SD 7.54 years; 7/27, 26% men). The primary outcomes were electroencephalographic activity (at rest and during a modified version of the Eriksen flanker task) and heart rate variability (at rest), PPTs, and pressure pain intensity ratings. The secondary outcomes were pain, disability, psychological functioning (mood, anxiety, kinesiophobia, pain catastrophizing, and fear-avoidance beliefs), and cognitive performance (percentage of hits and reaction times).

Results

After the intervention, frequency analysis of electroencephalographic resting-state data showed increased beta-2 (16-23 Hz; 0.0020 vs 0.0024; P=.02) and beta-3 (23-30 Hz; 0.0013 vs 0.0018; P=.03) activity. In addition, source analyses revealed higher power density of beta (16-30 Hz) at the anterior cingulate cortex and alpha (8-12 Hz) at the postcentral gyrus and lower power density of delta (2-4 Hz) at the cuneus and precuneus. Both groups also improved depression (7.74 vs 5.15; P=.01), kinesiophobia (22.91 vs 20.87; P=.002), activity avoidance (14.49 vs 12.86; P<.001), helplessness (6.38 vs 4.74; P=.02), fear-avoidance beliefs (35 vs 29.11; P=.03), and avoidance of physical activity (12.07 vs 9.28; P=.01) scores, but there was an increase in the disability score (6.08 vs 7.5; P=.01). No significant differences between the groups or sessions were found in heart rate variability resting-state data, electroencephalographic data from the Eriksen flanker task, PPTs, subjective ratings, or cognitive performance.

Conclusions

Both intervention modalities increased mainly beta activity at rest and improved psychological functioning. Given the limitations of our study, conclusions must be drawn carefully and further research will be needed. Nevertheless, to the best of our knowledge, this is the first study reporting electroencephalographic changes in patients with CLBP after an mHealth intervention.

Trial Registration

ClinicalTrials.gov NCT04576611; https://clinicaltrials.gov/ct2/show/NCT04576611

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use, and acceptability, of digital health technologies in musculoskeletal physical therapy: A survey of physical therapists and patients

Objectives

Determine (a) frequency of digital health use to obtain/record clinical information (pre‐COVID‐19); (b) willingness to use digital technologies among physical therapists and patients with musculoskeletal conditions.

Methods

102 physical therapists, and 103 patients were recruited in Australia. An electronic survey ascertained (a) demographic/clinical characteristics, (b) frequency of methods to obtain and record clinical information; (c) willingness to use digital technologies to support musculoskeletal care.

Results

Physical therapists mostly used non‐digital methods to obtain subjective (e.g., face‐to‐face questioning, n = 98; 96.1%) and objective information (e.g., visual estimation, n = 95; 93.1%). The top three digital health technologies most frequently used by therapists: photo‐based image capture (n = 19; 18.6%), accessing information logged/tracked by patients into a mobile app (n = 14; 13.7%), and electronic systems to capture subjective information that the patient fills in (n = 13; 12.7%). The top three technologies used by patients: activity trackers (n = 27; 26.2%), logging/tracking health information on mobile apps or websites (n = 12; 11.7%), and entering information on a computer (n = 12; 7.8%). Physical therapists were most willing to use technologies for: receiving diagnostic imaging results (n = 99; 97.1%), scheduling appointments (n = 92; 90.2%) and capturing diagnostic results (n = 92; 90.2%). Patients were most willing to use technologies for receiving notifications about health test results (n = 91; 88.4%), looking up health information (n = 83; 80.6%) and receiving personalised alerts/reminders (n = 80; 77.7%).

Conclusions

Physical therapists and patients infrequently use digital health technologies to support musculoskeletal care, but expressed some willingness to consider using them for select functions.

Using Intervention Mapping to Develop a Decision Support System–Based Smartphone App (selfBACK) to Support Self-management of Nonspecific Low Back Pain: Development and Usability Study

Background

International guidelines consistently endorse the promotion of self-management for people with low back pain (LBP); however, implementation of these guidelines remains a challenge. Digital health interventions, such as those that can be provided by smartphone apps, have been proposed as a promising mode of supporting self-management in people with chronic conditions, including LBP. However, the evidence base for digital health interventions to support self-management of LBP is weak, and detailed descriptions and documentation of the interventions are lacking. Structured intervention mapping (IM) constitutes a 6-step process that can be used to guide the development of complex interventions.

Objective

The aim of this paper is to describe the IM process for designing and creating an app-based intervention designed to support self-management of nonspecific LBP to reduce pain-related disability.

Methods

The first 5 steps of the IM process were systematically applied. The core processes included literature reviews, brainstorming and group discussions, and the inclusion of stakeholders and representatives from the target population. Over a period of >2 years, the intervention content and the technical features of delivery were created, tested, and revised through user tests, feasibility studies, and a pilot study.

Results

A behavioral outcome was identified as a proxy for reaching the overall program goal, that is, increased use of evidence-based self-management strategies. Physical exercises, education, and physical activity were the main components of the self-management intervention and were designed and produced to be delivered via a smartphone app. All intervention content was theoretically underpinned by the behavior change theory and the normalization process theory.

Conclusions

We describe a detailed example of the application of the IM approach for the development of a theory-driven, complex, and digital intervention designed to support self-management of LBP. This description provides transparency in the developmental process of the intervention and can be a possible blueprint for designing and creating future digital health interventions for self-management.