mHealth for pediatric chronic pain: state of the art and future directions

Roadmap to the 'Chronic Pain GPS for Adolescents' Intervention: Content and Design Considerations for a Group Peer Support Intervention

OBJECTIVES

A biopsychosocial approach to understanding and treating pain is crucial; however, there are limited socially targeted interventions for adolescents with chronic pain (ACP). Peer support interventions implemented with other populations are associated with positive outcomes. ACPs perceive peer support to have high potential value. This study explored the preferences of ACP regarding the content and design of a group peer support intervention.

METHODS

Fourteen ACP (M age : 15.21 y; 9 females; 3 males, 1 nonbinary, and 1 gender questioning) completed a virtual interview and survey. Interviews were analyzed using inductive qualitative content analysis, and surveys were analyzed using descriptive statistics.

RESULTS

Adolescents described how they want to both talk and do activities together within a fun and casual environment with a facilitator present-ideally, someone with lived experience of chronic pain. Preferences were for a medium-sized group intervention that was in-person, at a consistent time on a weekday after school, and semi-structured. Barriers to attending and engaging in the potential group peer intervention were also discussed.

DISCUSSION

ACPs desire a facilitated socially focused intervention that provides them with the opportunity to spend time with other ACPs. A group peer support environment where ACPs can provide and receive peer support through sharing their experiences with others who understand them as well as engage in activities was described. The findings from this study provide insights for the development of a group peer support intervention.

A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain

ABSTRACT

Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.

Help overcoming pain early, a brief person-centred intervention for adolescents with chronic pain in a school setting, may improve symptoms of insomnia

Introduction and aims

Chronic pain and symptoms of insomnia affect large numbers of adolescents and early interventions are prioritized. The aim of the current study was to evaluate potential secondary effects of the intervention, Help Overcoming Pain Early (HOPE), on symptoms of insomnia and self-rated health.

Methods

The study included non-randomized aggregated data from the active and control conditions in a previously conducted randomized controlled trial evaluating the efficacy of HOPE, after the participants in the control condition also had received the intervention. Symptoms of insomnia were assessed with the Minimal Insomnia Symptom Scale and self-rated health was assessed with one item, at the start of the intervention, post intervention, and at a six-month follow-up. Baseline variables included age, gender, pain localization, pain impact, school absence and symptoms of depression (assessed with the Center for Epidemiological Studies Depression Scale for Children). Inferential analyzes were performed using Linear Mixed Models (LMM). Effect sizes were evaluated by calculating Cohen's d.

Results

There were statistically significant improvements in symptoms of insomnia at the six-month follow-up, and statistically significant improvements in self-rated health at the end of the intervention and at the six-month follow-up. Effect sizes were small across outcomes and assessments.

Discussion and conclusion

Results illustrated significant but small improvements in symptoms of insomnia and self-rated health in adolescents with chronic pain following the HOPE intervention. Although caution is needed when assessing the findings, results illustrate the potential utility of an accessible brief early intervention in a school context.

Exploring User Visions for Modeling mHealth Apps Toward Supporting Patient-Parent-Clinician Collaboration and Shared Decision-making When Treating Adolescent Knee Pain in General Practice: Workshop Study

BACKGROUND

Long-standing knee pain is one of the most common reasons for adolescents (aged 10-19 years) to consult general practice. Generally, 1 in 2 adolescents will continue to experience pain after 2 years, but exercises and self-management education can improve the prognosis. However, adherence to exercises and self-management education interventions remains poor. Mobile health (mHealth) apps have the potential for supporting adolescents' self-management, enhancing treatment adherence, and fostering patient-centered approaches. However, it remains unclear how mHealth apps should be designed to act as tools for supporting individual and collaborative management of adolescents' knee pain in a general practice setting.

OBJECTIVE

The aim of the study was to extract design principles for designing mHealth core features, which were both sufficiently robust to support adolescents' everyday management of their knee pain and sufficiently flexible to act as enablers for enhancing patient-parent collaboration and shared decision-making.

METHODS

Overall, 3 future workshops were conducted with young adults with chronic knee pain since adolescence, parents, and general practitioners (GPs). Each workshop followed similar procedures, using case vignettes and design cards to stimulate discussions, shared construction of knowledge and elicit visions for mHealth designs. Young adults and parents were recruited via social media posts targeting individuals in Northern Jutland. GPs were recruited via email and cold calling. Data were transcribed and analyzed thematically using NVivo (QSR International) coding software. Extracted themes were synthesized in a matrix to map tensions in the collaborative space and inform a conceptual model for designing mHealth core-features to support individual and collaborative management of knee pain.

RESULTS

Overall, 38% (9/24) young adults with chronic knee pain since adolescence, 25% (6/24) parents, and 38% (9/24) GPs participated in the workshops. Data analysis revealed how adolescents, parents, and clinicians took on different roles within the collaborative space, with different tasks, challenges, and information needs. In total, 5 themes were identified: adolescents as explorers of pain and social rules; parents as supporters, advocates and enforcers of boundaries; and GPs as guides, gatekeepers, and navigators or systemic constraints described participants' roles; collaborative barriers and tensions referred to the contextual elements; and visions for an mHealth app identified beneficial core features. The synthesis informed a conceptual model, outlining 3 principles for consolidating mHealth core features as enablers for supporting role negotiation, limiting collaborative tensions, and facilitating shared decision-making.

CONCLUSIONS

An mHealth app for treating adolescents with knee pain should be designed to accommodate multiple users, enable them to shift between individual management decision-making, take charge, and engage in role negotiation to inform shared decision-making. We identified 3 silver-bullet principles for consolidating mHealth core features as enablers for negotiation by supporting patient-GP collaboration, supporting transitions, and cultivating the parent-GP alliance.

Potential effects of virtual interventions for menopause management: a systematic review

IMPORTANCE

Menopausal women are one of the fastest growing demographic groups globally. Virtual interventions have emerged as alternate avenues for menopausal women to manage and cope with their symptoms.

OBJECTIVE

The purpose of this review is to summarize existing research on the potential effects of virtual interventions for menopause management.

EVIDENCE REVIEW

This systematic review was written in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, PsychINFO, CINAHL, AgeLine, ERIC, ProQuest, Nursing and Allied Health Database, PsychARTICLES, and Sociology Database were used for literature search and searched from conception to December 2021. Original studies, including randomized controlled trials and quasi-experimental studies, were included if they evaluated a virtual intervention for menopause management and investigated the effects of these interventions on physical and psychosocial outcomes and/or the feasibility of these interventions among menopausal women. Included studies were published in peer-reviewed journals and assessed for quality using the Critical Appraisal Skills Program Checklists.

FINDINGS

A total of 16 articles were included in this review. Virtual interventions have the potential to improve physical health outcomes including body weight/body mass index/waist circumference, pain, blood pressure, and cholesterol. However, conflicting results were identified for the outcomes of vasomotor and endocrine symptoms, sleep, and sexual functioning. Virtual interventions might also improve psychosocial outcomes, including knowledge and patient-physician communication, although conflicting results were again identified for treatment decision-making ability, quality of life, and anxiety and depression. Virtual interventions were feasible in terms of being usable and cost-effective, and eliciting satisfaction and compliance among menopausal women.

CONCLUSIONS AND RELEVANCE

Virtual interventions might have the potential to improve the physical and psychosocial health outcomes of menopausal women, although some conflicting findings arose. Future studies should focus on including diverse menopausal women and ethnic minorities, conducting research within low- to middle-income countries and communities, further exploring intervention design to incorporate features that are age and culture sensitive, and conducting full randomized controlled trials to evaluate the effects of the interventions.

Rapid Transition to Virtual Assessment and Treatment in an Interdisciplinary Randomized Clinical Trial for Youth With Chronic Pain: Adaptations and Implications for Future Trials

OBJECTIVES

COVID-19 abruptly halted in-person clinical care and research requiring a shift to virtual assessment and treatment. This unexpected transition of a 2-arm randomized controlled trial (RCT) examining interdisciplinary graded exposure treatment (GET Living) compared with multidisciplinary pain management for youth with chronic pain provided an opportunity to implement the first remotely delivered exposure treatment and remotely delivered biomechanical assessment for pediatric chronic pain. Here we describe these new approaches and provide lessons learned to inform future efforts in digital health care.

METHODS

A total of 68 youth (M=14.2 y; 80.9% female) were enrolled in the RCT (n=31 in-person, n=5 hybrid, n=32 virtual, n=9 withdrew). Of those withdrawn, n=3 withdrew due to COVID-19 related reasons. Some RCT elements required slight modification (eg, e-consent, actigraphy deployment, recruitment, and screening), while others were significantly altered (eg, session format and lab-based biomechanical assessment). Data from exit interviews were also examined to assess perspectives on the virtual format transition.

RESULTS

Results showed an increased enrollment rate when virtual care was an option (70.7%) compared with in-person (44.3%). Equivalent rates of completion for daily assessment (in-person, 72.8%; virtual, 73.3) were also observed, and participants described enhanced experience when able to complete exercises and exposures in their home environment during session (vs. a rehabilitation gym) allowing for genuine in vivo exposures (eg, household chores, riding bicycles).

DISCUSSION

Overall, our data demonstrate acceptability, feasibility, and equivalent patient engagement to virtual treatment. Novel methods implemented in this RCT can inform trial design and measures of clinical endpoints for future digital health interventions.

"Hey Siri, Help Me Take Care of My Child": A Feasibility Study With Caregivers of Children With Special Healthcare Needs Using Voice Interaction and Automatic Speech Recognition in Remote Care Management

Background

About 23% of households in the United States have at least one child who has special healthcare needs. As most care activities occur at home, there is often a disconnect and lack of communication between families, home care nurses, and healthcare providers. Digital health technologies may help bridge this gap.

Objective

We conducted a pre-post study with a voice-enabled medical note taking (diary) app (SpeakHealth) in a real world setting with caregivers (parents, family members) of children with special healthcare needs (CSHCN) to understand feasibility of voice interaction and automatic speech recognition (ASR) for medical note taking at home.

Methods

In total, 41 parents of CSHCN were recruited. Participants completed a pre-study survey collecting demographic details, technology and care management preferences. Out of 41, 24 participants completed the study, using the app for 2 weeks and completing an exit survey. The app facilitated caregiver note-taking using voice interaction and ASR. An exit survey was conducted to collect feedback on technology adoption and changes in technology preferences in care management. We assessed the feasibility of the app by descriptively analyzing survey responses and user data following the key focus areas of acceptability, demand, implementation and integration, adaptation and expansion. In addition, perceived effectiveness of the app was assessed by comparing perceived changes in mobile app preferences among participants. In addition, the voice data, notes, and transcriptions were descriptively analyzed for understanding the feasibility of the app.

Results

The majority of the recruited parents were 35–44 years old (22, 53.7%), part of a two-parent household (30, 73.2%), white (37, 90.2%), had more than one child (31, 75.6%), lived in Ohio (37, 90.2%), used mobile health apps, mobile note taking apps or calendar apps (28, 68.3%) and patient portal apps (22, 53.7%) to track symptoms and health events at home. Caregivers had experience with voice technology as well (32, 78%). Among those completed the post-study survey (in Likert Scale 1–5), ~80% of the caregivers agreed or strongly agreed that using the app would enhance their performance in completing tasks (perceived usefulness; mean = 3.4, SD = 0.8), the app is free of effort (perceived ease of use; mean = 3.2, SD = 0.9), and they would use the app in the future (behavioral intention; mean = 3.1, SD = 0.9). In total, 88 voice interactive patient notes were generated with the majority of the voice recordings being less than 20 s in length (66%). Most noted symptoms and conditions, medications, treatment and therapies, and patient behaviors. More than half of the caregivers reported that voice interaction with the app and using transcribed notes positively changed their preference of technology to use and methods for tracking symptoms and health events at home.

Conclusions

Our findings suggested that voice interaction and ASR use in mobile apps are feasible and effective in keeping track of symptoms and health events at home. Future work is suggested toward using integrated and intelligent systems with voice interactions with broader populations.

Contrasting the Expectations and Experiences of Mobile Health Use on Chronic Pain: A Questionnaire Study (Preprint)

Background

Chronic pain is a prolonged condition that deteriorates one's quality of life. Treating chronic pain requires a multicomponent approach, and in many cases, there are no “silver bullet” solutions. Mobile health (mHealth) is a rapidly expanding category of solutions in digital health with proven potential in chronic pain management.

Objective

This study aims to contrast the viewpoints of 2 groups of people with chronic pain concerning mHealth: people who have adopted the use of mHealth and those who have not. We highlight the benefits of mHealth solutions for people with chronic pain and the perceived obstacles to their increased adoption. We also provide recommendations to encourage people to try mHealth solutions as part of their self-care.

Methods

The Prolific crowdsourcing platform was used to collect crowdsourced data. A prescreening questionnaire was released to determine what type of pain potential participants have and whether they are currently using mHealth solutions for chronic pain. The participants were invited based on their experience using mHealth to manage their pain. Similar questions were presented to mHealth users and nonusers. Qualitative and quantitative analyses were performed to determine the outcomes of this study.

Results

In total, 31 responses were collected from people (aged 19-63 years, mean 31.4, SD 12.1) with chronic pain who use mHealth solutions. Two-thirds (n=20, 65%) of the users identified as female and 11 (35%) as male. We matched these mHealth users with an equal number of nonusers: 31 responses from the pool of 361 participants in the prescreening questionnaire. The nonusers’ ages ranged from 18 to 58 years (mean 30.8, SD 11.09), with 15 (50%) identifying as female and 15 (50%) as male. Likert-scale questions were analyzed using the Mann-Whitney-Wilcoxon (MWW) test. Results showed that the 2 groups differed significantly on 10 (43%) of 23 questions and shared similar views in the remaining 13 (57%). The most significant differences were related to privacy and interactions with health professionals. Of the 31 mHealth users, 12 (39%) declared that using mHealth solutions has made interacting with health or social care professionals easier (vs n=22, 71%, of nonusers). The majority of the nonusers (n=26, 84%) compared with about half of the users (n=15, 48%) expressed concern about sharing their data with, for example, third parties.

Conclusions

This study investigated how mHealth is currently used in the context of chronic pain and what expectations mHealth nonusers have for mHealth as a future chronic pain management tool. Analysis revealed contrasts between mHealth use expectations and actual usage experiences, highlighting privacy concerns toward mHealth solutions. Generally, the results showed that nonusers are more concerned about data privacy and expect mHealth to facilitate interacting with health professionals. The users, in contrast, feel that such connections do not exist.

Exposure in Vivo as a Treatment Approach to Target Pain-Related Fear: Theory and New Insights From Research and Clinical Practice

Pain-related fear (PRF) can be a significant factor contributing to the development and maintenance of pain-related disability in individuals with persistent pain. One treatment approach to target PRF and related avoidance behavior is exposure in vivo (EXP). EXP has a long history in the field of anxiety, a field that is constantly evolving. This Perspective outlines recent theoretical advancements and how they apply to EXP for PRF, including suggestions for how to optimize inhibitory learning during EXP; reviews mechanistic work from neuroimaging supporting the targeting of PRF in people with chronic pain; and focuses on clinical applications of EXP for PRF, as EXP is moving into new directions regarding who is receiving EXP (eg, EXP in chronic secondary pain) and how treatment is provided (EXP in primary care with a crucial role for physical therapists). Considerations are provided regarding challenges, remaining questions, and promising future perspectives.

IMPACT

For patients with chronic pain who have elevated pain-related fear (PRF), exposure is the treatment of choice. This Perspective highlights the inhibitory learning approach, summarizes mechanistic work from experimental psychology and neuroimaging regarding PRF in chronic pain, and describes possible clinical applications of EXP in chronic secondary pain as well as in primary care.

Rapid Evidence and Gap Map of virtual care solutions across a stepped care continuum for youth with chronic pain and their families in response to the COVID-19 pandemic

ABSTRACT

Poor access to pediatric chronic pain care is a longstanding concern. The COVID-19 pandemic has necessitated virtual care delivery at an unprecedented pace and scale. We conducted a scoping review to create an interactive Evidence and Gap Map of virtual care solutions across a stepped care continuum (ie, from self-directed to specialist care) for youth with chronic pain and their families. Review methodology was codesigned with 8 youth with chronic pain and 7 parents/caregivers. Data sources included peer-reviewed scientific literature, gray literature (app stores and web sites), and a call for innovations. Records were independently coded and assessed for quality. Overall, 185 records were included (105 scientific records, 56 apps, 16 web sites, and 8 innovations). Most virtual care solutions were applicable across pediatric chronic pain diagnoses, with the greatest proportion at lower levels of stepped care (ie, >100 self-guided apps and web sites). Virtual delivery of psychological strategies was common. Evidence gaps were noted at higher levels of stepped care (ie, requiring more resource and health professional involvement), integration with health records, communication with health professionals, web accessibility, and content addressing social/family support, medications, school, substance use, sleep, diet, and acute pain flares or crises. Evidence and Gap Maps are a novel visual knowledge synthesis tool, which enable rapid evidence-informed decision-making by patients and families, health professionals, and policymakers. This evidence and gap map identified high-quality virtual care solutions for immediate scale and spread and areas with no evidence in need of prioritization. Virtual care should address priorities identified by youth with chronic pain and their families.

Engagement during a Mixed In-Person and Remotely Delivered Psychological Intervention for Youth with Functional Abdominal Pain Disorders and Anxiety

Functional abdominal pain disorders (FAPD) are common disabling pain conditions frequently associated with co-occurring mental health problems such as anxiety. Psychological therapies such as cognitive behavioral therapy (CBT) have been shown to be effective. Therefore, it is important to understand participant engagement (i.e., use of intervention tools) to such approaches, and if engagement impacts treatment response. The Aim to Decrease Anxiety and Pain Treatment (ADAPT) is an effective psychological treatment approach using a blend of in-person sessions and interventionist phone support with self-paced web modules to manage pain and anxiety. The current study used a mixed-methods approach to investigate micro-level and macro-level participant engagement during the ADAPT program. In-person/phone session attendance was high (>95%) although scheduling adjustments were common (25.5%). Varied levels of engagement with web tools were observed. Thematic analysis also revealed variability in patterns of use. Additionally, while participants indicated they generally understood how to use certain skills (e.g., problem solving, detective thinking), and these skills were effective in managing symptoms during treatment, these activities were generally underutilized. Further, participant engagement did not predict response to the ADAPT intervention. These findings are important as the demand for accessible psychotherapeutic tools to manage pain and anxiety is likely to remain high.

Evaluating Telehealth Implementation in the Context of Pediatric Chronic Pain Treatment during COVID-19

Telehealth has emerged as a promising healthcare delivery modality due to its ability to ameliorate traditional access-level barriers to treatment. In response to the onset of the novel coronavirus (COVID-19) pandemic, multidisciplinary pain clinics either rapidly built telehealth infrastructure from the ground up or ramped up existing services. As the use of telehealth increases, it is critical to develop data collection frameworks that guide implementation. This applied review provides a theoretically-based approach to capitalize on existing data sources and collect novel data to inform virtually delivered care in the context of pediatric pain care. Reviewed multisource data are (1) healthcare administrative data; (2) electronic chart review; (3) clinical health registries; and (4) stakeholder feedback. Preliminary telehealth data from an interdisciplinary pediatric chronic pain management clinic (PPMC) serving youth ages 8–17 years are presented to illustrate how relevant implementation outcomes can be extracted from multisource data. Multiple implementation outcomes were assessed, including telehealth adoption rates, patient clinical symptoms, and mixed-method patient-report telehealth satisfaction. This manuscript provides an applied roadmap to leverage existing data sources and incorporate stakeholder feedback to guide the implementation of telehealth in pediatric chronic pain settings through and beyond COVID-19. Strengths and limitations of the modeled data collection approach are discussed within the broader context of implementation science.

Online multidisciplinary interventions for paediatric chronic pain: A content analysis

BACKGROUND

Many online interventions for paediatric chronic pain have been developed and evaluated. In accordance with the biopsychosocial model, the recommended treatment approach for chronic pain is multidisciplinary. Despite this, multidisciplinary components within existing online interventions have not been examined. The objective of the present review was to summarise and evaluate the content of existing online interventions for paediatric chronic pain by mapping intervention content to evidence-based guidelines for chronic pain management.

METHODS

Interventions were identified using an updated systematic review. Nine chronic pain management strategies that reflect evidence-based guidance for multidisciplinary chronic pain management were defined by the authors, examples of which include 'pain education', 'activity pacing' and 'physiotherapy'. Identified interventions were then coded against the target strategies. These codes were compiled descriptively to provide an overview of how well each chronic pain management strategy was represented across the dataset, and which interventions represented the most strategies.

RESULTS

Thirty-five articles, relating to 13 unique interventions for paediatric chronic pain management were identified; few encompassed a complete multidisciplinary approach. Many CBT-based interventions included multidisciplinary elements. Across interventions, physiotherapy and non-pharmacological physical therapies were the least represented chronic pain management strategies.

CONCLUSIONS

The content analysis revealed a lack of online interventions encompassing complete multidisciplinary pain management. It is important that new interventions for paediatric chronic pain management are evidence-based and reflect current best practice guidelines. Established intervention development approaches should be utilised and include a process evaluation to help identify which intervention components are effective in which contexts.

SIGNIFICANCE

This content analysis of online interventions for paediatric chronic pain highlights the need for multidisciplinary practices in pain management to be translated into online interventions. Improving the availability of pain management resources is essential for many families who cannot attend specialist pain clinics, particularly in the context of the COVID-19 pandemic. There is potential for new resources, as well as for established resources, to be further developed to deliver a broader range of pain management content.

Best practices for virtual care to support youth with chronic pain and their families: a rapid systematic review to inform health care and policy during COVID-19 and beyond

Supplemental Digital Content is Available in the Text.

Evidence-informed guidance to better leverage, implement, and select virtual care platforms for pediatric chronic pain, and identified knowledge gaps are in need of additional research.

The COVID-19 pandemic has acutely challenged health systems and catalyzed the need for widescale virtual care and digital solutions across all areas of health, including pediatric chronic pain. The objective of this rapid systematic review was to identify recommendations, guidelines, and/or best practices for using virtual care to support youth with chronic pain and their families (CRD42020184498). MEDLINE, CINAHL, Embase, APA PsychINFO, and Web of Science were searched the week of May 25, 2020, for English language peer-reviewed articles published since 2010 that (1) discussed children and adolescents aged <18 years reporting any type of chronic pain (ie, pain lasting >3 months); (2) focused on any type of virtual care (eg, telephone, telehealth, telemedicine, mHealth, eHealth, online, or digital); and (3) reported on guidelines, best practices, considerations, or recommendations for virtual care. Abstract and full text screening and data extraction were performed in duplicate. Meta-ethnography was used to synthesize concepts across articles. Of 4161 unique records screened, 16 were included addressing diverse virtual care and pediatric chronic pain conditions. Four key themes were identified: (1) opportunities to better leverage virtual care, (2) direct effective implementation of virtual care, (3) selection of virtual care platforms, and (4) gaps in need of further consideration when using virtual care to support youth with chronic pain and their families. No existing guidelines for virtual care for pediatric chronic pain were identified; however, best practices for virtual care were identified and should be used by health professionals, decision makers, and policymakers in implementing virtual care.