Use of handheld wireless technology for a home-based sickle cell pain management protocol

Pain Management Mobile Applications: A Systematic Review of Commercial and Research Efforts

Shared decision making is crucial in the pain domain. The subjective nature of pain demands solutions that can facilitate pain assessment and management. The aim of the current study is to review the current trends in both the commercial and the research domains in order to reveal the key issues and guidelines that could further help in the effective development of pain-focused apps. We searched for scientific publications and commercial apps in 22 databases and the two major app stores. Out of 3612 articles and 336 apps, 69 met the requirements for inclusion following the PRISMA guidelines. An analysis of their features (technological approach, design methodology, evaluation strategy, and others) identified critical points that have to be taken into consideration in future efforts. For example, commercial and research efforts target different types of pain, while no participatory design is followed in the majority of the cases examined. Moreover, the evaluation of the final apps remains a challenge that hinders their success. The examined domain is expected to experience a substantial increase. More research is needed towards the development of non-intrusive wearables and sensors for pain detection and assessment, along with artificial intelligence techniques and open data.

Tailoring a Digital Mental Health Program for Patients With Sickle Cell Disease: Qualitative Study

BACKGROUND

Depression and other mental health disorders are prevalent among people living with chronic health conditions. Although digital cognitive behavioral therapy (CBT) is considered an effective treatment, African American individuals are less likely to engage in and adhere to digital therapies for mental health disorders compared with White individuals.

OBJECTIVE

The aim of this study was to understand digital CBT mental health treatment perceptions and preferences of African American individuals with sickle cell disease (SCD).

METHODS

African American individuals with SCD from various US locations were invited to participate in a series of focus groups. Participants were introduced to a health coach-supported mental health app and then asked a series of questions about the usability and appeal of the program as well as, more generally, what would make a digital mental health program effective for them. The authors reviewed the focus group transcripts and conducted a qualitative analysis of the results.

RESULTS

A total of 25 people participated in 5 focus groups. Overall, 5 primary themes emerged regarding how app content and related coaching could be modified to enhance digital CBT engagement. These themes included connection with others living with SCD, the personalization of app content and coaching, characteristics of coaches, journaling and pain tracking, and considerations for optimal engagement.

CONCLUSIONS

Enhancing the user experience by making digital CBT tools relevant to patient populations is critical for optimizing program engagement and its uptake. Our findings highlight potential strategies to modify and design digital CBT tools for users with SCD and may also be applicable to patients with other chronic conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04587661; https://clinicaltrials.gov/ct2/show/NCT04587661.

Self-management interventions for children and young people with sickle cell disease: A systematic review

BACKGROUND

Increasing numbers of interventions are being developed to support self-management for children and young people (CYP) with sickle cell disease (SCD), but no systematic review has systematically synthesized this evidence regarding their characteristics, effectiveness, acceptability and feasibility for all published intervention types.

METHODS

The Joanna Briggs Institute guidelines for mixed-method reviews were followed. A systematic search of eight databases and key journals was conducted from their inception to November 2021. Primary research of self-management interventions targeting CYP with SCD aged 8-24 years and reporting any health/social outcome and acceptability data were included. Design-specific standardized critical appraisal instruments were used. Two independent reviewers screened and appraised the articles. A third reviewer resolved disagreements.

RESULTS

Of 1654 articles identified, 38 studies were included. Methodological quality was moderate. Most studies evaluated SCD education, psycho-behavioural, psychosocial and skills training and/or social support interventions. They appear to demonstrate short-term improvements in knowledge, social functioning and medical adherence outcomes. Interventions that were multifaceted in content, combined technological platforms and in-person group-based formats and involved peers, family and care providers were more acceptable and effective. The long-term impact of interventions was limited, including CYP's involvement in the intervention development and implementation.

CONCLUSIONS

There is inconclusive evidence for any self-management programme. Nonetheless, support from family, peers and care providers appears to be important for self-management interventions' effectiveness and acceptability. Future research needs to prioritize CYP involvement in both intervention design and delivery, their wider social context and include CYP with SCD from non-Black backgrounds.

PATIENT AND PUBLIC CONTRIBUTION

Three young people with SCD recruited acted as the review advisors. They were formally trained in the review process and involved in every aspect of the review: the design, conduct and interpretation of the findings. CYP involvement in the interventions' development and implementation was analysed as part of the review. This systematic review was conducted as part of a wider research project titled: Understanding fatigue experiences of CYP with SCD to guide the co-development of a fatigue self-management intervention. Two of the young advisors involved in the review were also involved in the development of the project funding application.

A Stress and Pain Self-management mHealth App for Adult Outpatients With Sickle Cell Disease: Protocol for a Randomized Controlled Study

BACKGROUND

This paper describes the research protocol for a randomized controlled trial of a self-management intervention for adults diagnosed with sickle cell disease (SCD). People living with SCD experience lifelong recurrent episodes of acute and chronic pain, which are exacerbated by stress.

OBJECTIVE

This study aims to decrease stress and improve SCD pain control with reduced opioid use through an intervention with self-management relaxation exercises, named You Cope, We Support (YCWS). Building on our previous findings from formative studies, this study is designed to test the efficacy of YCWS on stress intensity, pain intensity, and opioid use in adults with SCD.

METHODS

A randomized controlled trial of the short-term (8 weeks) and long-term (6 months) effects of YCWS on stress, pain, and opioid use will be conducted with 170 adults with SCD. Patients will be randomized based on 1:1 ratio (stratified on pain intensity [≤5 or >5]) to be either in the experimental (self-monitoring of outcomes, alerts or reminders, and use of YCWS [relaxation and distraction exercises and support]) or control (self-monitoring of outcomes and alerts or reminders) group. Patients will be asked to report outcomes daily. During weeks 1 to 8, patients in both groups will receive system-generated alerts or reminders via phone call, text, or email to facilitate data entry (both groups) and intervention use support (experimental). If the participant does not enter data after 24 hours, the study support staff will contact them for data entry troubleshooting (both groups) and YCWS use (experimental). We will time stamp and track patients' web-based activities to understand the study context and conduct exit interviews on the acceptability of system-generated and staff support. This study was approved by our institutional review board.

RESULTS

This study was funded by the National Institute of Nursing Research of the National Institutes of Health in 2020. The study began in March 2021 and will be completed in June 2025. As of April 2022, we have enrolled 45.9% (78/170) of patients. We will analyze the data using mixed effects regression models (short term and long term) to account for the repeated measurements over time and use machine learning to construct and evaluate prediction models. Owing to the COVID-19 pandemic, the study was modified to allow for mail-in consent process, internet-based consent process via email or Zoom videoconference, devices delivered by FedEx, and training via Zoom videoconference.

CONCLUSIONS

We expect the intervention group to report reductions in pain intensity (primary outcome; 0-10 scale) and in stress intensity (0-10 scale) and opioid use (Wisepill event medication monitoring system), which are secondary outcomes. Our study will contribute to advancing the use of nonopioid therapy such as guided relaxation and distraction techniques for managing SCD pain.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04484272; https://clinicaltrials.gov/ct2/show/NCT04484272.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/33818.

Effects of Music Therapy on Quality of Life in Adults with Sickle Cell Disease (MUSIQOLS): A Mixed Methods Feasibility Study

Purpose

To investigate the feasibility, acceptability, and preliminary efficacy of a 6-session music therapy protocol on self-efficacy, quality of life, and coping skills in adults with sickle cell disease (SCD).

Patients and Methods

Using a mixed-methods intervention design, adults with SCD (ages 21–57; mean age 32.33) were randomized (1:1) to either 1) a 6-session music therapy (MT) intervention (n = 12) or 2) waitlist control (WLC) (n = 12) using stratified randomization where factors were age in years (≤30 vs >30), and sex (male, female). All participants completed two weeks of daily electronic pain diary entries and self-efficacy, quality of life, and coping skills measures before and after their assigned study condition to explore preliminary efficacy. MT participants were taught music exercises accessed via smartphone and subsequently interviewed to determine feasibility and acceptability.

Results

The enrollment rate was 89%. All study measures were completed, with high rates of electronic pain diary completion at baseline (70%) and 2-week follow-up (66%). Interviews revealed two overall themes related to MT participants’ experience: 1) participants learned new self-management skills and 2) MT improved participants’ ability to cope with pain. MT participants demonstrated 100% attendance. In preliminary analyses, MT participants demonstrated significant improvements (means ± SD) in self-efficacy (5.42 ± 5.43, p = 0.008, d = 1.20), PROMIS sleep disturbance (−1.49 ± 6.68, p = 0.023, d = −0.99), PROMIS pain interference (−2.10 ± 4.68, p = 0.016, d = −1.06), and ASCQ-Me social functioning impact scores (2.97 ± 6.91, p = 0.018, d = 1.05) compared to WLC participants.

Conclusion

Preliminary findings support the feasibility and acceptability of music therapy for home use in adults with SCD. While music therapy may assist adults with SCD in improving self-efficacy and quality of life, subsequent, fully-powered clinical research is needed to determine its efficacy.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/_BQrUCZt1R4

Pain Experience, Physical Function, Pain Coping, and Catastrophizing in Children With Sickle Cell Disease Who Had Normal and Abnormal Sensory Patterns

CONTEXT

Sickle cell disease (SCD) is associated with recurrent pain that could lead to abnormal sensory patterns (ASPs).

OBJECTIVES

The purpose of this study is to compare children with SCD who had normal sensory patterns (NSPs) and ASPs in pain experience, physical function, pain coping, and pain catastrophizing.

METHODS

Children with quantitative sensory testing data were selected from a larger study that examined pain and symptoms in children with SCD. Comparisons were made between children with NSP (n = 35; 13.9 ± 1.9 years) and ASP (n = 13; 12.8 ± 1.9 years). Children completed the Adolescent Pediatric Pain Tool, Functional Disability Inventory, Pain Coping Questionnaire, and Pain Catastrophizing Scale.

RESULTS

No significant differences were found in pain intensity (2.9 ± 3.0 vs. 2.6 ± 2.8 on 0-10 Visual Analogue Scale) between the NSP and ASP, respectively. The most common marked pain sites for both groups were lower extremities (22.9%), head and neck (20.8%), and upper extremities (20.8%). Functional Disability Inventory scores were significantly worse in ASP (38.5%) compared with NSP (11.4%). The ASP group had significantly worse scores in emotion-focused pain coping subscales.

CONCLUSION

Children with SCD with ASP had worse functional disability, were expressing more affective pain quality, and had emotion-focused pain coping compared with NSP. Future studies are needed to examine the effectiveness of physical activities on the physical function as well as psychosocial interventions such as peer support and creative arts expression to minimize development of ASP in children with SCD.

Towards an Effective Patient Health Engagement System Using Cloud-Based Text Messaging Technology

Patient and health provider interaction via text messaging (TM) has become an accepted form of communication, often favored by adolescents and young adults. While integration of TM in disease management has aided health interventions and behavior modifications, broader adoption is hindered by expense, fixed reporting schedules, and monotonic communication. A low-cost, flexible TM reporting system (REMOTES) was developed using inexpensive cloud-based services with features of two-way communication, personalized reporting scheduling, and scalable and secured data storage. REMOTES is a template-based reporting tool adaptable to a wide-range of complexity in response formats. In a pilot study, 27 adolescents with sickle cell disease participated to assess feasibility of REMOTES in both inpatient and outpatient settings. Subject compliance with at least one daily self-report pain query was 94.9% (112/118) during inpatient and 91.1% (327/359) during outpatient, with an overall accuracy of 99.2% (970/978). With use of a more complex 8-item questionnaire, 30% (7/21) inpatient and 66.6% (36/54) outpatient responses were reported with 98.1% (51/52) reporting accuracy. All participants expressed high pre-trial expectation (88%) and post-trial satisfaction (89%). The study suggests that cloud-based text messaging is feasible and an easy-of-use solution for low-cost and personalized patient engagement.

Self-management recommendations for sickle cell disease: A content analysis of websites

This authors report on the findings of a study designed to establish website-based self-management recommendations for sickle cell disease. Google and Yahoo search engines were used to search the World Wide Web. Purposive sampling was used to select 28 websites that met the inclusion criteria. Data were manually collected from health education materials and subjected to qualitative content analysis. Self-management was conceptualized as actions involving preventive health, self-monitoring, self-diagnosing, and self-treatment. The results show that the websites recommend more self-management actions for preventive health and self-treatment than for self-monitoring and self-diagnosis. Frequent oral fluid intake, limitation of overactivity, eating a healthy diet, avoiding extreme temperatures, and infections were the most common preventive health recommendations. Daily pain monitoring and general bodily inspections were the most frequent self-monitoring recommendations. Commonly cited self-diagnostic indicators were fever, persistent pain, enlarged spleen, and leg ulcers. The use of analgesics and nonpharmacological measures were regularly cited for self-treatment. Most recommendations were assessed as clinically safe as they align with standards for sickle cell management. Nurses and other professionals should teach clients how to assess the credibility of websites.

The Role of Cognitive Behavioral Therapy in Opioid Use Reduction in Pediatric Sickle Cell Disease: Protocol for a Systematic Review

Background

Sickle cell disease (SCD) is a genetic disorder of red blood cells that results in acute and chronic health problems, including painful syndromes. Opioid analgesia is the mainstay of moderate to severe pain management in SCD, although adjunctive psychosocial approaches such as cognitive behavioral therapy (CBT) are increasingly incorporated. CBT has been used in populations of various ages to address a wide range of issues, such as mood disorders and chronic pain. It is unclear if effective CBT reduces the use of opioids to manage pain in pediatric SCD.

Objective

The aim of this study is to evaluate the association between CBT and decreased opioid use in children with SCD.

Methods

In this systematic review protocol, we describe our approach to applying predetermined eligibility criteria to searches of PubMed (including Medline), Embase, Cochrane, Web of Science, and PsycINFO databases, as well as Google Scholar and grey literature. In particular, we will use keywords to search for English-language studies of individuals with SCD aged 21 years old and younger published before November 2018. Keywords will allow us to assess for the primary outcome—total use of opioid medications—and the secondary outcomes—pain intensity and emotional functioning—during pain management using a combined opioid and CBT approach, opioids alone, or CBT alone. The review team will use standardized abstraction forms to review articles at the title, abstract, and full-text levels. Finally, reviewers will assess the risk for bias, quality of evidence, and adequacy of data for quantitative versus qualitative synthesis. If meta-analysis is deemed inappropriate, a narrative review will be conducted.

Results

We will report a summary of findings across studies that meet eligibility criteria to compare the extent to which adjunctive CBT is associated with decreased opioid use among children with SCD.

Conclusions

This systematic review will present the current state of the evidence on CBT and opioid use in pediatric SCD, which may inform clinical practice and health policy to support optimized pain management.

International Registered Report Identifier (IRRID)

PRR1-10.2196/13211

A Postoperative Pain Management Mobile App (Panda) for Children at Home After Discharge: Usability and Feasibility

Background

Emphasis on outpatient pediatric surgical procedures places the burden of responsibility for postoperative pain management on parents or guardians. Panda is a mobile phone app that provides scheduled medication alerts and allows parents to track their child’s pain and medication administration. We have previously tested and optimized the usability and feasibility of Panda within the hospital setting.

Objective

The purpose of this study was to evaluate and optimize the usability and feasibility of Panda for use at home based on alert response adherence (response to any medication notification within 1 hour) and parents’ satisfaction.

Methods

Parents or guardians of children aged 3 to 18 years undergoing day surgery were recruited to use Panda at home for 1 to 7 days to manage their scheduled medications and to assess their child’s pain. After the surgical procedure, a research assistant guided parents through app setup before independent use at home. We aimed to recruit 10 child-caregiver pairs in each of three rounds of evaluation. Each user’s adherence with the recommended medication alerts was analyzed through audit-trail data generated during the use of the app. We used the Computer System Usability Questionnaire and a poststudy phone interview to evaluate the app’s ease of use and identify major barriers to adoption. Suggestions provided during the interviews were used to improve the app between each round.

Results

Twenty-nine child-caregiver pairs participated in three rounds, using the app for 1 to 5 days. Alert response adherence (response to any medication notification within 1 hour) improved as the study progressed: participants responded to a median 30% (interquartile range [IQR] 22%-33%) of alerts within 1 hour in round 1, and subsequently to median 60% (IQR 44%-64%) in round 2 and median 64% (IQR 56%-72%) in round 3 (P=.005). Similarly, response times decreased from median 131 (IQR 77-158) minutes in round 1 to median 31 (IQR 18-61) minutes in round 2 and median 10 (IQR 2-14) minutes in round 3 (P=.002). Analysis of interview feedback from the first two rounds revealed usability issues, such as complaints of too many pages and trouble hearing app alerts, which were addressed to streamline app function, as well as improve visual appearance and audible alerts.

Conclusions

It is feasible for parents or guardians to use Panda at home to manage their child’s medication schedule and track their pain. Simple modifications to the app’s alert sounds and user interface improved response times.

Acceptability and Feasibility of a Mindfulness-Based Intervention for Pain Catastrophizing among Persons with Sickle Cell Disease

BACKGROUND

Few investigators have developed and tested nonpharmacological interventions for helping persons with sickle cell disease (SCD) manage persistent pain.

AIMS

The purpose of this pilot study was to examine the feasibility and acceptability of a mindfulness-based intervention (MBI) in adults with SCD and chronic pain and to gather preliminary data on its efficacy.

DESIGN

Data on feasibility and acceptability, including recruitment, retention, and attendance rates, were collected during a single-site, randomized control trial. Participants were randomly assigned to either a 6-session group telephonic MBI or a wait-listed control. Pain catastrophizing was assessed at baseline and at weeks 1, 3, and 6.

SETTING

Outpatient, comprehensive, interdisciplinary sickle cell disease center in the Southeast.

PARTICIPANTS/SUBJECTS

Adults at least 18 years of age with a self-reported diagnosis of sickle cell disease who self-identified as having chronic, non-cancer pain that persisted on most days for at least 6 months and adversely affected function and/or well-being.

METHODS

Seventy-eight adults were recruited; 18 (23%) declined to participate; 60 were randomly assigned to either the MBI (N = 40) or control (N = 20). Of those, 14 (35%) from the MBI and 12 (60%) from the control group withdrew immediately after random allocation, resulting in 34 evaluable cases (MBI: N = 26; control: N = 8).

RESULTS

Among the 26 assigned to MBI, the median number of sessions attended per person was 4; 7 (27%) attended all six sessions. Qualitative findings indicated that MBI participants viewed the program as acceptable and liked the telephonic format, community, and content. Reductions in pain catastrophizing outcomes were identified after intervention.

CONCLUSIONS

An MBI is feasible and acceptable for persons with SCD experiencing chronic pain. A larger randomized controlled trial to establish MBI efficacy on pain and related outcomes for SCD will provide nonpharmacologic, behavioral pain management options for nurses and other clinicians caring for persons with SCD and chronic pain.

Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents

BACKGROUND

This is the first update of a review published in 2015, Issue 1. Chronic pain is common during childhood and adolescence and is associated with negative outcomes, such as increased severity of pain, reduced function, and low mood. Psychological therapies, traditionally delivered face-to-face with a therapist, are efficacious at reducing pain intensity and disability. To address barriers to treatment access, such as distance and cost of treatment, technology is being used to deliver these psychological therapies remotely. Therapies delivered remotely, such as via the Internet, computer-based programmes, and smartphone applications, can be used to deliver treatment to children and adolescents with chronic pain.

OBJECTIVES

To determine the efficacy of psychological therapies delivered remotely compared to waiting list, treatment as usual, or active control treatments, for the management of chronic pain in children and adolescents.

SEARCH METHODS

We searched four databases (CENTRAL, MEDLINE, Embase, and PsycINFO) from inception to May 2018 for randomised controlled trials (RCTs) of remotely-delivered psychological interventions for children and adolescents with chronic pain. We searched for chronic pain conditions including, but not exclusive to, headache, recurrent abdominal pain, musculoskeletal pain, and neuropathic pain. We also searched online trial registries, reference sections, and citations of included studies for potential trials.

SELECTION CRITERIA

We included RCTs that investigated the efficacy of a psychological therapy delivered remotely via technology in comparison to an active, treatment as usual, or waiting-list control. We considered blended treatments, which used a combination of technology and up to 30% face-to-face interaction. Interventions had to be delivered primarily via technology to be included, and we excluded interventions delivered via telephone. We included studies that delivered interventions to children and adolescents (up to 18 years of age) with a chronic pain condition or where chronic pain was a primary symptom of their condition (e.g. juvenile arthritis). We included studies that reported 10 or more participants in each comparator arm, at each extraction point.

DATA COLLECTION AND ANALYSIS

We combined all psychological therapies in the analyses. We split pain conditions into headache and mixed (non-headache) pain and analysed them separately. We extracted pain severity/intensity, disability, depression, anxiety, and adverse events as primary outcomes, and satisfaction with treatment as a secondary outcome. We considered outcomes at two time points: first immediately following the end of treatment (known as 'post-treatment'), and second, any follow-up time point post-treatment between three and 12 months (known as 'follow-up'). We assessed risk of bias and all outcomes for quality using the GRADE assessment.

MAIN RESULTS

We found 10 studies with 697 participants (an additional 4 studies with 326 participants since the previous review) that delivered treatment remotely; four studies investigated children with headache conditions, one study was with children with juvenile idiopathic arthritis, one included children with sickle cell disease, one included children with irritable bowel syndrome, and three studies included children with different chronic pain conditions (i.e. headache, recurrent abdominal pain, musculoskeletal pain). The average age of children receiving treatment was 13.17 years.We judged selection, detection, and reporting biases to be mostly low risk. However, we judged performance and attrition biases to be mostly unclear. Out of the 16 planned analyses, we were able to conduct 13 meta-analyses. We downgraded outcomes for imprecision, indirectness of evidence, inconsistency of results, or because the analysis only included one study.Headache conditionsFor headache pain conditions, we found headache severity was reduced post-treatment (risk ratio (RR) 2.02, 95% confidence interval (CI) 1.35 to 3.01); P < 0.001, number needed to treat to benefit (NNTB) = 5.36, 7 studies, 379 participants; very low-quality evidence). No effect was found at follow-up (very low-quality evidence). There were no effects of psychological therapies delivered remotely for disability post-treatment (standardised mean difference (SMD) -0.16, 95% CI -0.46 to 0.13; P = 0.28, 5 studies, 440 participants) or follow-up (both very low-quality evidence). Similarly, no effect was found for the outcomes of depression (SMD -0.04, 95% CI -0.15 to 0.23, P = 0.69, 4 studies, 422 participants) or anxiety (SMD -0.08, 95% CI -0.28 to 0.12; P = 0.45, 3 studies, 380 participants) at post-treatment, or follow-up (both very low-quality evidence).Mixed chronic pain conditionsWe did not find any beneficial effects of psychological therapies for reducing pain intensity post-treatment for mixed chronic pain conditions (SMD -0.90, 95% CI -1.95 to 0.16; P = 0.10, 5 studies, 501 participants) or at follow-up. There were no beneficial effects of psychological therapies delivered remotely for disability post-treatment (SMD -0.28, 95% CI -0.74 to 0.18; P = 0.24, 3 studies, 363 participants) and a lack of data at follow-up meant no analysis could be run. We found no beneficial effects for the outcomes of depression (SMD 0.04, 95% CI -0.18 to 0.26; P = 0.73, 2 studies, 317 participants) and anxiety (SMD 0.53, 95% CI -0.63 to 1.68; P = 0.37, 2 studies, 370 participants) post-treatment, however, we are cautious of our findings as we could only include two studies in the analyses. We could not conduct analyses at follow-up. We judged the evidence for all outcomes to be very low quality.All conditionsAcross all chronic pain conditions, six studies reported minor adverse events which were not attributed to the psychological therapies. Satisfaction with treatment is described qualitatively and was overall positive. However, we judged both these outcomes as very low quality.

AUTHORS' CONCLUSIONS

There are currently a small number of trials investigating psychological therapies delivered remotely, primarily via the Internet. We are cautious in our interpretations of analyses. We found one beneficial effect of therapies to reduce headache severity post-treatment. For the remaining outcomes there was either no beneficial effect at post-treatment or follow-up, or lack of evidence to determine an effect. Overall, participant satisfaction with treatment was positive. We judged the quality of the evidence to be very low, meaning we are very uncertain about the estimate. Further studies are needed to increase our confidence in this potentially promising field.

A Systematic Literature Review of the Design Approach and Usability Evaluation of the Pain Management Mobile Applications

The increasing popularity of mHealth is a promising opportunity for pain self-management. Mobile apps can be easily developed, but understanding the design and usability will result in apps that can retain more users. This research aims at identifying, analyzing, and synthesizing the current state-of-the-art of: (a) the design approach and (b) usability assessment of pain management mobile applications. A systematic literature review was conducted on 27 studies retrieved from Medline, PubMed, EMBASE, Web of Science, and Scopus. The review revealed that most of the apps were for chronic pain. No app was specifically for men or for the elderly. None of the studies involved expert-based system inspection methods. Only one study used two different approaches of automated and empirical evaluation. We mapped the identified usability issues to ISO 9241-11 and ISO/IEC 25010, and aggregated the recommendations for improvement. Moreover, we also identified certain issues that are solely concerned with the patient’s behavior. We organized the issues into taxonomies of design considerations for building usable pain self-management mobile applications. As pain is prevalent among the elderly, pain management will be much needed while moving toward an aging society. However, we found that the involvement of the elderly in the development of pain management mobile apps is very minimal, which may affect the utility and usability of the apps.

Self-management recommendations for sickle cell disease: A Ghanaian health professionals' perspective

OBJECTIVE

To describe self-management recommendations for sickle cell disease (SCD) care among health professionals who manage SCD in Ghana.

METHOD

Nine health care professionals (nurses, doctors, and physician assistants) who work in SCD were interviewed. The semistructured interviews were recorded, transcribed, and analysed using the qualitative content analysis method. Self-management recommendations were conceptualised as preventive health, self-monitoring, self-diagnosis, self-treatment, and self-evaluation.

RESULTS

Preventive health recommendations were the commonest, where the professionals described similar topics including avoidance of cold temperature, frequent oral hydration, and healthy nutrition. Self-monitoring recommendations included regular checks for pallor, urine colour, and splenic enlargement. Self-diagnosis recommendations were captured as warning signs and included pain, fever, unusual feelings, and enlarged spleen. Pain and fever management were the focus of most self-treatment advice, and there were some self-treatment recommendations for dactylitis, anaemia, and priapism. There was considerable variation in the strategies recommended for the management of individual SCD-related problems.

CONCLUSION

Ghanaian health professionals involved in SCD care provide limited and inconsistent self-management recommendations. There is a need for the development of SCD standards and guidelines that support effective self-management. Health professionals working in SCD require continuing education in self-management.

In-hospital usability and feasibility evaluation of Panda, an app for the management of pain in children at home

BACKGROUND

Postoperative pain in children is often poorly managed at home, leading to slower functional recovery, poor oral intake, sleep disturbances, and behavioral changes. Panda is a smartphone application (app) designed to support parents in assessing their child's pain and managing medications.

AIMS

The aim of this study was to evaluate the Panda app's usability and feasibility in hospital prior to testing the app at home.

METHODS

The study comprised two phases. Phase I evaluated Panda's usability with nurses, parents, and adolescents using simulated scenarios. Usability was measured by task completion rate, user error rates, and the Computer Systems Usability Questionnaire. Phase II evaluated Panda's feasibility by observing parents/guardians of pediatric patients using the app on the postsurgical ward. Feasibility was measured using response frequency and delay following app notifications from an audit trail of app function, and parental satisfaction from an interview. Feedback was used to guide iterative app improvements.

RESULTS

In Phase I, 13 nurses, 12 parents, and 5 adolescents evaluated the app. A total of 103 usability issues were identified, analyzed, and addressed. In Phase II, 29 parents responded to a total of 151 app notifications, with 84% responding within 1 hour in the final round of testing; 93% of participants reported the app was easy to use, and rated the app with a median [interquartile range] Computer Systems Usability Questionnaire score of 2 [1-4]. Significant barriers to use included lack of flexibility in the medication scheduling, low volume of alert sounds, and the extra time spent on medication safety checks.

CONCLUSION

Panda's usability was improved and its feasibility demonstrated in the controlled hospital environment. The next step is to evaluate its feasibility for use at home.

Availability of researcher-led eHealth tools for pain assessment and management: barriers, facilitators, costs, and design

INTRODUCTION

Numerous eHealth tools for pain assessment and management have been developed and evaluated with promising results regarding psychometric properties, efficacy, and effectiveness. Although considerable resources are spent on developing and evaluating these tools with the aim of increasing access to care, current evidence suggests they are not made available to end users, reducing their impact and creating potential research waste.

METHODS

This study consisted of 2 components: (1) a systematic review of eHealth tools for pediatric pain assessment and/or management published in the past 10 years, and (2) an online survey, completed by the authors of identified tools, of tool availability, perceived barriers or facilitators to availability, grant funding used, and a validated measure of user-centeredness of the design process (UCD-11).

RESULTS

Ninety articles (0.86% of citations screened) describing 53 tools met inclusion criteria. Twenty-six survey responses were completed (49.06%), 13 of which (50.00%) described available tools. Commonly endorsed facilitators of tool availability included researchers' beliefs in tool benefits to the target population and research community; barriers included lack of infrastructure and time. The average cost of each unavailable tool was $314,425.31 USD ($3,144,253.06 USD total, n = 10). Authors of available tools were more likely to have followed user-centered design principles and reported higher total funding.

CONCLUSION

Systemic changes to academic and funding structures could better support eHealth tool availability and may reduce potential for research waste. User-centered design and implementation science methods could improve the availability of eHealth tools and should be further explored in future studies.

Efficacy of Internet-delivered cognitive-behavioral therapy for the management of chronic pain in children and adolescents: A systematic review and meta-analysis

BACKGROUND

Pediatric chronic pain is relatively common in the world. Although cognitive behavior therapy (CBT) has been shown to be efficacious in children and adolescents, it is generally recognized that availability and accessibility of CBT are limited. While Internet-delivered cognitive-behavioral therapy (ICBT) performs better in these areas.

OBJECTIVES

This systematic review aims to evaluate the clinical effects of ICBT for chronic pain in youth when compared with the control treatments.

METHODS

We searched electronic databases to identify randomized controlled trials that compared ICBT with the control therapy for pediatric chronic pain. The primary outcomes were 95% confidence intervals and mean difference or standardized mean difference in change of pain intensity and activity limitations.

RESULTS

Four trials met the inclusion criteria with a total of 404 participants of whom 208 received ICBT. Compared with pretreatment, children reported significant, medium to large benefits on pain intensity, activity limitations, and parental protective behaviors after receiving ICBT immediately. Significant small to medium effects were found for outcomes of depressive symptoms, anxiety, and sleep quality from baseline to post-treatment in the ICBT group. But most measures of ICBT did not show statistically significant superiority to those of the control conditions, except parental protective behaviors. Generally children and their parents were highly acceptable and satisfied with ICBT.

CONCLUSION

ICBT for physical and psychological conditions in youth with chronic pain is a full potential therapy; it can be successful on clinically effects and socioeconomic benefits. However, only limited data supported the conclusion, we require further methodologically robust trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017069811.

Mobile health intervention for youth with sickle cell disease: Impact on adherence, disease knowledge, and quality of life

BACKGROUND

Adherence to illness self-management among youth with sickle cell disease (SCD) positively impacts health outcomes and decreases overall healthcare costs. Despite this, children with SCD face several barriers to adherence, with adherence rates that remain moderate to low. The current feasibility study examined the Intensive Training Program (ITP), a mobile health (mHealth) intervention for youth with SCD designed to promote disease knowledge, adherence, and patient-provider communication.

PROCEDURE

Youth with SCD prescribed hydroxyurea between ages 7-18 completed baseline disease knowledge and psychosocial assessments and then were provided with the ITP app. Youth participated in the 90-day ITP, during which they completed three education modules, tracked adherence through daily self-recorded videos on the app, and received video messages from providers. Participants completed poststudy knowledge, psychosocial, and feasibility questionnaires. Medication possession ratio (MPR) was obtained via pharmacy-refill rates.

RESULTS

Thirty-two youths (mean age = 13.0 years) participated, with an average adherence tracking rate of 0.6 (standard deviation = 0.34). All participants demonstrated increased MPR (0.57-0.74, P < 0.001, d = 0.75) and disease knowledge (59.6-88.6%, P < 0.001). There was variable engagement in the ITP; completers demonstrated significantly better SCD-related functioning (P < 0.05), higher parent-reported treatment functioning (P < 0.05), and lower pain impact than noncompleters of the ITP (P < 0.05).

CONCLUSIONS

Results support the ITP can feasibly be implemented to promote adherence among youth with SCD. All participants demonstrated increased adherence and disease knowledge. However, there was variable engagement and only intervention completers showed improvements in psychosocial outcomes. Further research is needed to evaluate long-term outcomes and ways to promote engagement in mHealth interventions among the youth.

Patient-Centered eHealth Interventions for Children, Adolescents, and Adults With Sickle Cell Disease: Systematic Review

BACKGROUND

Sickle cell disease is an inherited blood disorder that affects over 100,000 Americans. Sickle cell disease-related complications lead to significant morbidity and early death. Evidence supporting the feasibility, acceptability, and efficacy of self-management electronic health (eHealth) interventions in chronic diseases is growing; however, the evidence is unclear in sickle cell disease.

OBJECTIVE

We systematically evaluated the most recent evidence in the literature to (1) review the different types of technological tools used for self-management of sickle cell disease, (2) discover and describe what self-management activities these tools were used for, and (3) assess the efficacy of these technologies in self-management.

METHODS

We reviewed literature published between 1995 and 2016 with no language limits. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and other sources. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers screened titles and abstracts, assessed full-text articles, and extracted data from articles that met inclusion criteria. Eligible studies were original research articles that included texting, mobile phone-based apps, or other eHealth interventions designed to improve self-management in pediatric and adult patients with sickle cell disease.

RESULTS

Of 1680 citations, 16 articles met all predefined criteria with a total of 747 study participants. Interventions were text messaging (4/16, 25%), native mobile apps (3/16, 19%), Web-based apps (5/16, 31%), mobile directly observed therapy (2/16, 13%), internet-delivered cognitive behavioral therapy (2/16, 13%), electronic pill bottle (1/16, 6%), or interactive gamification (2/16, 13%). Interventions targeted monitoring or improvement of medication adherence (5/16, 31%); self-management, pain reporting, and symptom reporting (7/16, 44%); stress, coping, sleep, and daily activities reporting (4/16, 25%); cognitive training for memory (1/16, 6%); sickle cell disease and reproductive health knowledge (5/16, 31%); cognitive behavioral therapy (2/16, 13%); and guided relaxation interventions (1/16, 6%). Most studies (11/16, 69%) included older children or adolescents (mean or median age 10-17 years; 11/16, 69%) and 5 included young adults (≥18 years old) (5/16, 31%). Sample size ranged from 11 to 236, with a median of 21 per study: <20 in 6 (38%), ≥20 to <50 in 6 (38%), and >50 participants in 4 studies (25%). Most reported improvement in self-management-related outcomes (15/16, 94%), as well as high satisfaction and acceptability of different study interventions (10/16, 63%).

CONCLUSIONS

Our systematic review identified eHealth interventions measuring a variety of outcomes, which showed improvement in multiple components of self-management of sickle cell disease. Despite the promising feasibility and acceptability of eHealth interventions in improving self-management of sickle cell disease, the evidence overall is modest. Future eHealth intervention studies are needed to evaluate their efficacy, effectiveness, and cost effectiveness in promoting self-management in patients with sickle cell disease using rigorous methods and theoretical frameworks with clearly defined clinical outcomes.

Keppi: A Tangible User Interface for Self-Reporting Pain

Motivated by the need to support those self-managing chronic pain, we report on the development and evaluation of a novel pressure-based tangible user interface (TUI) for the self-report of scalar values representing pain intensity. Our TUI consists of a conductive foam-based, force-sensitive resistor (FSR) covered in a soft rubber with embedded signal conditioning, an ARM Cortex-M0 microprocessor, and Bluetooth Low Energy (BLE). In-lab usability and feasibility studies with 28 participants found that individuals were able to use the device to make reliable reports with four degrees of freedom as well map squeeze pressure to pain level and visual feedback. Building on insights from these studies, we further redesigned the FSR into a wearable device with multiple form factors, including a necklace, bracelet, and keychain. A usability study with an additional 7 participants from our target population, elderly individuals with chronic pain, found high receptivity to the wearable design, which offered a number of participant-valued characteristics (e.g., discreetness) along with other design implications that serve to inform the continued refinement of tangible devices that support pain self-assessment.

Cognitive Testing of an Electronic Version of the Faces Pain Scale-Revised with Pediatric and Adolescent Sickle Cell Patients

BACKGROUND

Patient diaries and pain scales can capture the course and complications of pain managed at home in children. The Faces Pain Scale-Revised (FPS-R) is a validated scale showing reliability in children, but it has not been validated in children with sickle cell disease (SCD).

OBJECTIVE

The purpose of this study was to evaluate comprehension and usability of an electronic modified version of the FPS-R among pediatric patients with SCD.

METHODS

This was a cross-sectional, qualitative study involving in-person interviews with children/adolescents from the USA and their parents/legal guardians. Interviews involved cognitive debriefing and usability testing of the FPS-R.

RESULTS

In total, 22 children with SCD aged 4-17 years participated. Children aged 4-6 were generally unable to demonstrate clear understanding of the FPS-R and its response scale. Overall, children aged ≥7 years understood the instrument and could complete it on the electronic device, although children aged 7-8 often needed assistance from the parent. Children aged 9-17 years were able to read and complete the instrument independently. Most participants considered the electronic device easy to use.

CONCLUSIONS

The FPS-R was shown to be a comprehensible and usable pain measure for children aged 7-17 with SCD and to be beneficial for future clinical studies.

Differences in Sensory Pain, Expectation, and Satisfaction Reported by Outpatients with Cancer or Sickle Cell Disease

BACKGROUND

Patients with sickle cell disease (SCD) report pain scores that appear greater than those reported in a meta-analysis for patients with cancer, but statistical comparisons of the pain scores from both populations have not been published.

AIMS

The goal of the study described here was to compare pain outcomes reported by outpatients with cancer or SCD.

DESIGN

Descriptive comparative study.

SETTING

Outpatient oncology or sickle cell clinics.

SUBJECTS

The participants were outpatients (N = 415) from three studies: (1) 106 patients with SCD, 93% African-American (referent group); (2) 140 patients with cancer, 90% Caucasian (race discordant); (3) 169 patients with cancer, 20% Caucasian, 65% African-American (race concordant).

METHODS

Patients completed the PAINReportIt including pain location, quality, pattern, intensity, expectation, satisfaction, and demographic questions. Analyses included the χ² test, analysis of variance, and regression.

RESULTS

Outpatients with SCD reported more pain location sites than the race-discordant (p < .001) and race-concordant (p < .001) cancer groups; higher pain quality than the race-discordant (p < .001) and race-concordant (p < .001) groups; and greater pain pattern scores than the race-discordant (p < .001) and race-concordant (p < .001) groups. The race-concordant group reported higher worst pain intensity than the SCD (p < .001) and race-discordant (p = .002) groups. The three groups did not differ significantly on pain expectation (p = .06). Regarding satisfaction with pain level, there was a significant difference between the race-concordant and SCD (p = .006) groups, but not between the race-discordant and SCD (p = .12) groups or between the race-discordant and race-concordant (p = .49) groups.

CONCLUSIONS

Outpatients with SCD reported three of four sensory pain parameters that were greater than those reported by outpatients with cancer. A better understanding of these differences is pertinent to improving pain outcomes.

Aplicativos móveis para o manejo da doença falciforme: revisão integrativa

Resumo Objetivo Investigar, na literatura nacional e internacional, os aplicativos móveis existentes desenvolvidos para gerenciamento da doença falciforme. Métodos Estudo de revisão integrativa, conduzido nas bases de dados Medline/via PubMed, BVS, Current Index to Nursing and Allied Health Literature (Cinahl), Web of Science e Scopus, no período de setembro de 2016 a março de 2018. Os artigos selecionados foram analisados de acordo com a Agency for Healthcare Research and Quality (AHQR). Resultados Integraram esta revisão 12 artigos, sendo dois da Web of Science e o restante da PubMed. Conclusão Esta revisão mostrou a incipiência de estudos que contemplam o desenvolvimento de aplicativos móveis no contexto da doença falciforme. No Brasil não foram identificados estudos que utilizem aplicativos móveis direcionados à população com doença falciforme, apesar da alta incidência desta condição crônica. Este estudo aponta para a necessidade de desenvolvimento de aplicativos móveis como importante recurso educativo que possa apoiar a prática de autocuidado das pessoas com doença falciforme.

Successful utilization of an electronic pain diary in a multinational phase 3 interventional study of pediatric sickle cell anemia

BACKGROUND/AIMS

Patients with sickle cell anemia can experience recurrent pain episodes, which affect quality of life. The reported prevalence of pain is higher in studies using patient diaries than in healthcare facility utilization data. Determining Effects of Platelet Inhibition on Vaso-Occlusive Events was a multinational study that assessed the efficacy and safety of prasugrel in reducing the rate of vaso-occlusive events in children with sickle cell anemia (NCT01794000) and included an electronic patient-reported outcome diary to record pain occurrence. We aimed to capture diary completion rates and compliance in children who used the electronic patient-reported outcome diary during the Determining Effects of Platelet Inhibition on Vaso-Occlusive Events study and examine factors contributing to diary completion rates and compliance.

METHODS

Daily electronic patient-reported outcome diary data were collected for up to 9 months in Determining Effects of Platelet Inhibition on Vaso-Occlusive Events participants aged 4 to <18 years in Africa, the Americas, Europe, and the Middle East. The questionnaires were available in 11 languages/dialects for collecting subjective (pain intensity, activity interference) and objective (study drug use, analgesic use, school attendance) data. Pain intensity was measured using the Faces Pain Scale-Revised. Data were entered by participants or caregivers and transferred wirelessly each day to a central database. Diary completion rates were the number of daily diary entries divided by the total number of expected daily diary entries. Percentages of participants who were compliant with the diary (≥80% diary completion) were calculated.

RESULTS

A total of 311 participants received a diary; 268 provided diary data through Month 9. Diary completion rates and compliance were high throughout the collection period and across all groups and regions, despite no games being included on the device. For subjective data, the overall completion rate was 94.4%, and 92.6% of participants were compliant. For objective data, the overall completion rate was 93.3%, and 89.7% of participants were compliant. Completion rates and compliance differed significantly by age and region and were higher for 4 to <12 year olds and very much higher for participants from Africa and the Middle East. Caregivers almost always entered data for participants <6 years and rarely entered data for participants ≥12 years. Comparing participant-entered and caregiver-entered data, pain intensity score data were more consistent for 4 to <12 year olds than older children, but pain intensity scores for older children were higher when entered by caregivers.

CONCLUSION

With appropriate design, participant training, and sufficient monitoring, an electronic patient-reported outcome diary can capture daily sickle cell-related pain data in large multinational studies. Providing a mechanism for caregiver reporting is particularly valuable for participants <6 years and may also facilitate compliance in older children who experience high levels of pain.

Adherence and barriers to hyperinsufflation in children with congenital muscular dystrophy

BACKGROUND

Congenital muscular dystrophy (CMD) is a rare, inherited neuromuscular disease characterized by progressive muscle weakness, thoracic insufficiency, and ultimately respiratory failure. Adherence to respiratory therapies in children with neuromuscular disorders is unknown. This study examined the multimodal assessment of adherence and barriers to 15 min, twice daily hyperinsufflation in children with CMD. Adherence was hypothesized to be greater than 50% and discomfort, embarrassment, and difficulty finding time were hypothesized to be barriers.

METHODS

Participants included 18 children with CMD. Personalized hyperinsufflation settings were determined based on pressure-volume measurements at each study visit. Adherence was measured by a daily phone diary (DPD) and by electronic data download from the hyperinsufflation device. The DPD was conducted twice over a 48-hr period to capture a weekend and weekday, with the goal being 60 min of hyperinsufflation over the 48 hr (100% adherence). The hyperinsufflation objective electronic data reflected daily use of hyperinsufflation for the same 48-hr period. Data from DPD and the corresponding hyperinsufflation device data were used for analyses.

RESULTS

Adherence to hyperinsufflation was 40% via DPD and 44% for electronic data, with strong convergence between methods (r = 0.75, P < 0.001). Surprisingly, 53% of participants reported no barriers despite low adherence. Social distractions and family obligations were identified as barriers. There were no differences in adherence between those who did and did not endorse barriers to hyperinsufflation (DPD: t(13) = 0.44, P = n.s.; hyperinsufflation device: t(13) = -0.23, P = n.s.).

CONCLUSION

Adherence to hyperinsufflation is a significant problem in children with CMD and families have difficulty identifying adherence barriers. An important next step is to encourage open dialog around adherence barriers and promote adherence behaviors via intervention. Pediatr Pulmonol. 2017; 52:939-945. © 2016 Wiley Periodicals, Inc.

Supporting the Self-Management of Chronic Pain Conditions with Tailored Momentary Self-Assessments

To better support the self-management of chronic pain, this paper investigates how those living with the condition prefer to self-assess their pain levels using smartphones. Our work consists of three stages: design ideation and review, an in-lab user study with 10 participants resulting in nine candidate interfaces, and a 3 week field trial of two further honed measures with 12 participants. This research firstly yields a better understanding of participants' strong and sometimes contrasting preferences regarding their self-assessment of pain intensity. We additionally contribute two novel interfaces that support accurate, quick, and repeated use along with other participant-valued interactions (e.g., familiar, relatable, and highly usable). In particular, we focus on designing tailored measures that both enhance respondent motivation as well as minimize the difficulty of meaningful self-assessment by supporting the cog-nitive effort in translating a subjective experience into a single numerical value.

Cognitive Behavior Therapy for Anxious and Depressed Youth: Improving Homework Adherence Through Mobile Technology

Background

Anxiety and mood disorders are the most common mental illnesses, peaking during adolescence and affecting approximately 25% of Canadians aged 14-17 years. If not successfully treated at this age, they often persist into adulthood, exerting a great social and economic toll. Given the long-term impact, finding ways to increase the success and cost-effectiveness of mental health care is a pressing need. Cognitive behavior therapy (CBT) is an evidence-based treatment for mood and anxiety disorders throughout the lifespan. Mental health technologies can be used to make such treatments more successful by delivering them in a format that increases utilization. Young people embrace technologies, and many want to actively manage their mental health. Mobile software apps have the potential to improve youth adherence to CBT and, in turn, improve outcomes of treatment.

Objective

The purpose of this project is to improve homework adherence in CBT for youth anxiety and/or depression. The objectives are to (1) design and optimize the usability of a mobile app for delivering the homework component of CBT for youth with anxiety and/or depression, (2) assess the app’s impact on homework completion, and (3) implement the app in CBT programs. We hypothesize that homework adherence will be greater in the app group than in the no-app group.

Methods

Phase 1: exploratory interviews will be conducted with adolescents and therapists familiar with CBT to obtain views and perspectives on the requirements and features of a usable app and the challenges involved in implementation. The information obtained will guide the design of a prototype. The prototype will be optimized via think-aloud procedures involving an iterative process of evaluation, modification, and re-evaluation, culminating in a fully functional version of the prototype that is ready for optimization in a clinical context. Phase 2: a usability study will be conducted to optimize the prototype in the context of treatment at clinics that provide CBT treatment for youth with anxiety and/or depression. This phase will result in a usable app that is ready to be tested for its effectiveness in increasing homework adherence. Phase 3: a pragmatic clinical trial will be conducted at several clinics to evaluate the impact of the app on homework adherence. Participants in the app group are expected to show greater homework completion than those in the no-app group.

Results

Phase 3 will be completed by September 2019.

Conclusions

The app will be a unique adjunct to treatment for adolescents in CBT, focusing on both anxiety and depression, developed in partnership with end users at every stage from design to implementation, customizable for different cognitive profiles, and designed with depression symptom tracking measures for youth made interoperable with electronic medical records.

Pain Assessment--Can it be Done with a Computerised System? A Systematic Review and Meta-Analysis

Background: Mobile and web technologies are becoming increasingly used to support the treatment of chronic pain conditions. However, the subjectivity of pain perception makes its management and evaluation very difficult. Pain treatment requires a multi-dimensional approach (e.g., sensory, affective, cognitive) whence the evidence of technology effects across dimensions is lacking. This study aims to describe computerised monitoring systems and to suggest a methodology, based on statistical analysis, to evaluate their effects on pain assessment. Methods: We conducted a review of the English-language literature about computerised systems related to chronic pain complaints that included data collected via mobile devices or Internet, published since 2000 in three relevant bibliographical databases such as BioMed Central, PubMed Central and ScienceDirect. The extracted data include: objective and duration of the study, age and condition of the participants, and type of collected information (e.g., questionnaires, scales). Results: Sixty-two studies were included, encompassing 13,338 participants. A total of 50 (81%) studies related to mobile systems, and 12 (19%) related to web-based systems. Technology and pen-and-paper approaches presented equivalent outcomes related with pain intensity. Conclusions: The adoption of technology was revealed as accurate and feasible as pen-and-paper methods. The proposed assessment model based on data fusion combined with a qualitative assessment method was revealed to be suitable. Data integration raises several concerns and challenges to the design, development and application of monitoring systems applied to pain.

Sickle Cell Disease: A Review of Nonpharmacological Approaches for Pain

CONTEXT

Sickle cell disease (SCD) is a life-threatening condition that affects more than seven million people worldwide. The most common complication experienced by persons living with SCD is pain. Evidence supports the use of nonpharmacologic therapies in managing psychological and social complications of pain in persons with SCD, but there is little consensus if these approaches can also be applied for the treatment of pain in SCD.

OBJECTIVES

To describe and synthesize the use of nonpharmacological therapies for reducing pain of any type and origin in persons with SCD.

METHODS

A literature search was conducted using PsycINFO, PsycARTICLES, PubMed, CINAHL, and Embase. Databases were searched using the following terms: sickle cell, pain, and nonpharmacological therapies. Interventions were graded for methodological quality and categorized as 1) peer-support group therapies, 2) educational/psychological therapies, and 3) skill-based therapies.

RESULTS

Twenty-eight nonpharmacological interventions for persons with SCD were examined. Of these studies, a wide variety of nonpharmacological interventions were tested. Twelve studies yielded significant improvements in pain, three studies reported no positive effect or differences between experimental and control conditions on pain or a pain-related outcome, and one study reported a negative or detrimental intervention effect.

CONCLUSION

Approximately half of the studies reviewed demonstrated success in alleviating pain, suggesting that patients are able to use nonpharmacological interventions to reduce pain with some degree of success. Questions still remain regarding the efficacy and generalizability of these interventions for persons with SCD.

Changes in coping, pain, and activity after cognitive-behavioral training: a randomized clinical trial for pediatric sickle cell disease using smartphones

OBJECTIVES

We examined the outcomes of a cognitive-behavioral therapy (CBT) intervention for pain in pediatric sickle cell disease (SCD) using smartphones as a novel delivery method.

MATERIALS AND METHODS

Forty-six children with SCD received CBT coping skills training using a randomized, waitlist control design. The intervention involved a single session of CBT training and home-based practice using smartphones for 8 weeks. Pre-post questionnaires between the randomized groups were used to evaluate changes in active psychological coping and negative thinking using the Coping Strategies Questionnaire. Daily diaries completed by the full sample during the treatment period were used to assess whether CBT skill use was related to reductions in next-day pain intensity and increases in same-day functional activity.

RESULTS

The pre-post group comparison suggested that the youth increased active psychological coping attempts with the intervention. Daily diary data indicated that when children used CBT skills on days with higher pain, there were reductions in next-day pain intensity. There was no such association between skill use and functional activity.

DISCUSSION

CBT coping skills training supported using smartphones can increase coping and reduce pain intensity for children with SCD; however, additions to the study protocols are recommended in future studies. Advantages and caveats of using smartphones are also discussed.

Apps and Adolescents: A Systematic Review of Adolescents' Use of Mobile Phone and Tablet Apps That Support Personal Management of Their Chronic or Long-Term Physical Conditions

Background

The prevalence of physical chronic or long-term conditions in adolescents aged 10-24 years is rising. Mobile phone and tablet mobile technologies featuring software program apps are widely used by these adolescents and their healthy peers for social networking or gaming. Apps are also used in health care to support personal condition management and they have considerable potential in this context. There is a growing body of literature on app use in health contexts, thereby making a systematic review of their effectiveness very timely.

Objective

To systematically review the literature on the effectiveness of mobile apps designed to support adolescents’ management of their physical chronic or long-term conditions.

Methods

We conducted a review of the English-language literature published since 2003 in five relevant bibliographical databases using key search terms. Two independent reviewers screened titles and abstracts using data extraction and quality assessment tools.

Results

The search returned 1120 hits. Of the 19 eligible full-text papers, four met our review criteria, reporting one pilot randomized controlled trial and three pretest/post-test studies. Samples ranged from 4 to 18 participants, with a combined sample of 46 participants. The apps reported were targeted at type 1 diabetes, asthma, and cancer. Two papers provided data for calculating effect size. Heterogeneity in terms of study design, reported outcomes, follow-up times, participants’ ages, and health conditions prevented meta-analyses. There was variation in whether adolescents received guidance in using the app or were solely responsible for navigating the app. Three studies reported some level of patient involvement in app design, development, and/or evaluation. Health professional involvement in the modelling stages of apps was reported in all studies, although it was not always clear whether specific clinical (as opposed to academic) expertise in working with adolescents was represented. The dearth of studies and the small overall sample size emphasizes the need for future studies of the development, evaluation, use, and effectiveness of mobile apps to support adolescents’ personal management of their conditions.

Conclusions

A key finding of the review is the paucity of evidence-based apps that exist, in contrast to the thousands of apps available on the app market that are not evidence-based or user or professional informed. Although we aimed to assess the effectiveness of apps, the dearth of studies meeting our criteria meant that we were unable to be conclusive in this regard. Based on the available evidence, apps may be considered feasible health interventions, but more studies involving larger sample sizes, and with patient and health professional input at all stages, are needed to determine apps’ acceptability and effectiveness. This review provides valuable findings and paves the way for future rigorous development and evaluation of health apps for adolescents with chronic or long-term conditions.

Barriers to care and quality of primary care services in children with sickle cell disease

AIMS

The aims of this study were: to (1) identify barriers to care in children with sickle cell disease; (2) examine the quality of primary care services received by these children and (3) examine the relationship between barriers to care and quality of primary care services in children with sickle cell disease.

BACKGROUND

Effective management in children with sickle cell disease requires early access to a comprehensive range of preventive screenings, urgent care treatments for vaso-occlusive pain crisis and ongoing prophylactic treatments.

DESIGN

A cross-sectional survey of parents of children with sickle cell disease was conducted between April-September 2011.

METHODS

Parents of children with sickle cell disease completed the Barriers to Care Questionnaire and Parent's Perceptions of Primary Care.

RESULTS

Parents of children with sickle cell disease (n = 38) reported health system barriers such as inability to contact doctors or clinics, extended wait times and inconvenient clinic hours. Some barriers were reported more frequently among children with concurrent sickle cell disease and asthma, compared with those children without a concurrent asthma condition. Parents who reported more barriers were least likely to perceive their care as accessible, comprehensive and coordinated.

CONCLUSIONS

Minimizing healthcare barriers may improve the quality of primary care services received by children with sickle cell disease and consequently prevent complications associated with sickle cell disease.

IMPLICATIONS FOR NURSING PRACTICE

Nurses and other care providers need to identify healthcare barriers, so that access, coordination, comprehensiveness and overall quality of primary care services may be improved in children with sickle cell disease.

iACT--an interactive mHealth monitoring system to enhance psychotherapy for adolescents with sickle cell disease

Sickle cell disease (SCD) is the most common inherited disease, and SCD symptoms impact functioning and well-being. For example, adolescents with SCD have a higher tendency of psychological problems than the general population. Acceptance and Commitment Therapy (ACT), a cognitive-behavioral therapy, is an effective intervention to promote quality of life and functioning in adolescents with chronic illness. However, traditional visit-based therapy sessions are restrained by challenges, such as limited follow-up, insufficient data collection, low treatment adherence, and delayed intervention. In this paper, we present Instant Acceptance and Commitment Therapy (iACT), a system designed to enhance the quality of pediatric ACT. iACT utilizes text messaging technology, which is the most popular cell phone activity among adolescents, to conduct real-time psychotherapy interventions. The system is built on cloud computing technologies, which provides a convenient and cost-effective monitoring environment. To evaluate iACT, a trial with 60 adolescents with SCD is being conducted in conjunction with the Georgia Institute of Technology, Children's Healthcare of Atlanta, and Georgia State University.

Self-management interventions for young people with chronic conditions: A systematic overview

OBJECTIVE

To provide a systematic overview of self-management interventions (SMI) for young people with chronic conditions with respect to content, formats, theories, and evaluated outcomes.

METHODS

Embase, Medline, PsycINFO, Web-of-Science, CINAHL, and Cochrane were searched. Reviews' reference lists were scrutinized. Selected studies were: Original research articles in English published between 2003 and March 2014; about the evaluation of SMI for 7 to 25-year-olds with somatic chronic conditions/physical disabilities; with clear outcomes and intervention descriptions. The classification of medical, role and emotion management served to review content. Formats, theories, and evaluated outcomes were summarized.

RESULTS

86 studies were reviewed. Most aimed at medical management and were unclear about theoretical bases. Although a variety of outcomes was evaluated and the distribution over self-management domains was quite unpredictable, outcomes conceptually related to specific content. A content-based framework for the evaluation of self-management interventions is presented.

CONCLUSIONS AND PRACTICE IMPLICATIONS

SMI relate to self-management tasks and skill-building. Yet, conceptualizations of self-management support often remained unclear and content focuses predominantly on the medical domain, neglecting psycho-social challenges for chronically ill young people. Future evaluations should match outcomes/themes to content and characteristics. Our framework and overview of SMI characteristics and outcomes may assist clinicians in providing self-management support.

Usability and Feasibility of an mHealth Intervention for Monitoring and Managing Pain Symptoms in Sickle Cell Disease: The Sickle Cell Disease Mobile Application to Record Symptoms via Technology (SMART)

Patients with sickle cell disease frequently experience severe pain events that lead to unplanned healthcare utilization. Mobile health tools (mHealth) may help prevent these events by providing remote monitoring and self-management support. This article describes the feasibility of the Sickle cell disease Mobile Application to Record symptoms via Technology (SMART), an mHealth app developed to help sickle cell disease patients monitor and manage their day-to-day symptoms. Fifteen patients recorded their pain intensity using a paper visual analog scale (VAS) and then repeated this measurement using an electronic VAS pain measure on SMART. Patients continued using SMART to record clinical symptoms, pain intensity, location and perceived severity, and treatment strategies for at least 28 days. Patient median age was 29 years (range 16-54); 60.0% were male. There was a high intraclass correlation between pain measurements entered on the paper VAS and SMART on the iPhone and the iPad We found a strong association between patient perceived pain severity and pain intensity entries using SMART (b = 1.71; p < 0.01). Daily compliance with SMART entries was a mean 75.0%, with a high of 85.7% in week 1 and low of 57.9% in week 4; however, one-third (n = 5) of the patients were 100.0% compliant even in week 4. Patients who were over age 35 or used an iPad for the study had the highest compliance rates. This study showed that SMART is a useable and feasible method for monitoring daily pain symptoms among adolescents and adults with sickle cell disease-related pain.

mHealth: a strategic field without a solid scientific soul. a systematic review of pain-related apps

BACKGROUND

Mobile health (mHealth) has undergone exponential growth in recent years. Patients and healthcare professionals are increasingly using health-related applications, at the same time as concerns about ethical issues, bias, conflicts of interest and privacy are emerging. The general aim of this paper is to provide an overview of the current state of development of mHealth.

METHODS AND FINDINGS

To exemplify the issues, we made a systematic review of the pain-related apps available in scientific databases (Medline, Web of Science, Gale, Psycinfo, etc.) and the main application shops (App Store, Blackberry App World, Google Play, Nokia Store and Windows Phone Store). Only applications (designed for both patients and clinicians) focused on pain education, assessment and treatment were included. Of the 47 papers published on 34 apps in scientific databases, none were available in the app shops. A total of 283 pain-related apps were found in the five shops searched, but no articles have been published on these apps. The main limitation of this review is that we did not look at all stores in all countries.

CONCLUSIONS

There is a huge gap between the scientific and commercial faces of mHealth. Specific efforts are needed to facilitate knowledge translation and regulate commercial health-related apps.

Feasibility of a symptom management intervention for adolescents recovering from a hematopoietic stem cell transplant

BACKGROUND

Adolescents undergoing a hematopoietic stem cell transplantation (HSCT) experience a variety of adverse effects and eating difficulties. Few interventions exist to assist patients with self-care after HSCT hospitalization. The Eating After Transplant (EAT!) program is a mobile phone applications developed to assist adolescents with self-management of common eating-related issues during HSCT recovery.

OBJECTIVE

This study examined the acceptability and usability of the EAT! program among adolescents and assessed the competency of the participants using the program after hospital discharge through the first 100 days after HSCT.

METHODS

A repeated-measures design was used to evaluate the EAT! application with 16 adolescent patients recovering from an allogeneic HSCT. Participants provided verbal feedback and used a Likert scale to rate acceptability and usability of the application. In addition, a tracking device monitored use of the application. Competency was measured with orientation time and independent demonstration of use of the application.

RESULTS

Acceptability remained high throughout the study, but use significantly decreased over time. Patients reported familiarity with the program's content as the reason for the declining use. Competency was excellent with a short orientation period and independent demonstration throughout the study.

CONCLUSIONS

A mobile phone application is a feasible intervention to educate adolescents with symptom management strategies. Future research needs to examine factors affecting sustainability of use over time.

IMPLICATIONS FOR PRACTICE

Healthcare providers need to continue to develop and evaluate innovative methods to educate adolescents on effective self-care strategies throughout HSCT recovery.

Hospital readmissions in patients with inflammatory bowel disease

OBJECTIVES

We aimed to identify the frequency and costs of, and the disease predictors and inpatient process issues that may predispose to, 30-day readmission for an inflammatory bowel disease (IBD) patient.

METHODS

IBD patients admitted to an inpatient gastroenterology service were followed for a time-to-readmission analysis assessing factors associated with readmission within 30 days.

RESULTS

Index admissions were more costly among those readmitted than among those not readmitted. Patients admitted with evidence of increased inflammation, infection, or obstruction or for dehydration or pain control had a higher risk of readmission. Patients treated with opioid analgesia during index admission were no less likely to be readmitted, and there was a 2.2-fold increase in readmissions when patients were discharged with no opioid analgesia. Scheduling variability and outpatient follow-up compliance were associated with readmission.

CONCLUSIONS

Predicting readmission is complex. A predictive model developed to be used at discharge yielded an area under the curve of 0.757.

Usability testing of a Smartphone for accessing a web-based e-diary for self-monitoring of pain and symptoms in sickle cell disease

We examined the usability of smartphones for accessing a web-based e-Diary for self-monitoring symptoms in children and adolescents with sickle cell disease (SCD). One group of participants (n = 10; mean age, 13.1 ± 2.4 y; 5 M; 5 F) responded to questions using precompleted paper-based measures. A second group (n = 21; mean age, 13.4 ± 2.4 y; 10 M; 11 F) responded based on pain and symptoms they experienced over the previous 12 hours. The e-Diary was completed with at least 80% accuracy when compared to paper-based measures. Symptoms experienced over the previous 12 hours included feeling tired (33.3%), headache (28.6%), coughing (23.8%), lack of energy/fatigue (19.0%), yellowing of the eyes (19.0%), pallor (19.0%), irritability (19.0%), stiffness in joints (19.0%), general weakness (14.3%), and pain (14.3%), rating on average as 2.0 ± 1.7 (on 0 to 10 scale). Overall, sleep was good (8.1 ± 1.4 on the 0 to 10 scale). In conclusion, children with SCD were able to use smartphones to access a web-based e-Diary for reporting pain and symptoms. Smartphones may improve self-reporting of symptoms and communication between patients and their health care providers, who may consequently be able to improve pain and symptom management in children and adolescents with SCD in a timely manner.

Sensitization to acute procedural pain in pediatric sickle cell disease: modulation by painful vaso-occlusive episodes, age, and endothelin-1

The impact of pain early in life is a salient issue for sickle cell disease (SCD), a genetic condition characterized by painful vaso-occlusive episodes (VOEs) that can begin in the first year of life and persist into adulthood. This study examined the effects of age and pain history (age of onset and frequency of recent VOEs) on acute procedural pain in children with SCD. Endothelin-1, a vaso-active peptide released during VOEs and acute tissue injury, and its precursor, Big Endothelin, were explored as markers of pain sensitization and vaso-occlusion. Sixty-one children with SCD (ages 2 to 18) underwent venipuncture at routine health visits. Procedural pain was assessed via child and caregiver reports and observational distress. Pain history was assessed using retrospective chart review. Three primary results were found: 1) younger age was associated with greater procedural pain across pain outcomes; 2) higher frequency of VOEs was associated with greater procedural pain based on observational distress (regardless of age); and 3) age was found to moderate the relationship between VOEs and procedural pain for child-reported pain and observational distress for children 5 years of age and older. Associations between the endothelin variables and pain prior to venipuncture were also observed.

PERSPECTIVE

For children with SCD, the child's age and recent pain history should be considered in procedural pain management. The endothelin system may be involved in preprocedure pain, but additional research is needed to understand the role of endothelins in pain sensitization.

Psychosocial treatments in pain management of sickle cell disease

The principal symptom of sickle cell disease (SCD) is pain. Many studies have been conducted on pain management strategies for this illness. There is recognition that psychosocial factors influence clinical disease outcomes; therefore, more attention is being provided to behavioral interventions that address psychosocial problems. This review examines the psychosocial interventions that have been researched for children and adults with SCD, the limitations of these studies, and barriers to implementing the treatments. The intervention receiving the most empirical support was cognitive-behavioral therapy. Additional research is needed to define the efficacy and effectiveness of the other psychosocial treatments. Suggestions for future investigations include conducting research that has better methodology, and providing more education for health care providers about psychosocial treatments and the importance of considering cultural factors in health care delivery. In addition, individuals with SCD need to have more information about their illness and better access to psychosocial interventions.

Randomized controlled trial of an Internet-delivered family cognitive-behavioral therapy intervention for children and adolescents with chronic pain

Cognitive-behavioral therapy (CBT) interventions show promise for decreasing chronic pain in youth. However, the availability of CBT is limited by many factors including distance to major treatment centers and expense. This study evaluates a more accessible treatment approach for chronic pediatric pain using an Internet-delivered family CBT intervention. Participants included 48 children, aged 11-17 years, with chronic headache, abdominal, or musculoskeletal pain and associated functional disability, and their parents. Children were randomly assigned to a wait-list control group or an Internet treatment group. Primary treatment outcomes were pain intensity ratings (0-10 NRS) and activity limitations on the Child Activity Limitations Interview, both completed via an online daily diary. In addition to their medical care, the Internet treatment group completed 8 weeks of online modules including relaxation training, cognitive strategies, parent operant techniques, communication strategies, and sleep and activity interventions. Youth randomized to the wait-list control group continued with the current medical care only. Findings demonstrated significantly greater reduction in activity limitations and pain intensity at post-treatment for the Internet treatment group and these effects were maintained at the three-month follow-up. Rate of clinically significant improvement in pain was also greater for the Internet treatment group than for the wait-list control group. There were no significant group differences in parental protectiveness or child depressive symptoms post-treatment. Internet treatment was rated as acceptable by all children and parents. Findings support the efficacy and acceptability of Internet delivery of family CBT for reducing pain and improving function among children and adolescents with chronic pain.