A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial

Observational pilot study on the influence of an app-based self-management program on the quality of life of women with endometriosis

PURPOSE

Endometriosis can significantly impair the quality of life of those affected. Multimodal self-help measures are recommended but often difficult to access. Smartphone apps have been shown to improve the quality of life for other conditions with chronic pain. The aim of this study was to examine whether there is evidence of beneficial effects of the smartphone app "Endo-App®" and whether a multicenter randomized controlled trial should be planned to substantiate these effects.

METHODS

In a sample of N = 106 women affected by endometriosis the present study determined the influence of the use of Endo-App® on their quality of life. Among others, the validated questionnaire Endometriosis Health Profile from Oxford University was used for this purpose.

RESULTS

The use of Endo-App® lead to a highly significant improvement in quality of life already after 2 weeks. A statistically significant change was found for nine out of ten measured variables of quality of life. A series of further analyses validated that the measured positive effects were not due to other confounding factors.

CONCLUSION

In summary, the results indicate that the quality of life of women with endometriosis improved by the digital self-management tool Endo-App®. More studies are needed to further explore the influence of the app on quality of life and as confirmatory evidence of beneficial effects. For this purpose, a randomized controlled trial should be conducted over a longer period of time.

TRIAL REGISTRATION

This trial is registered at clinicaltrials.gov under the registration number NCT05528601 on August 18, 2022. It was retrospectively registered.

Effectiveness of a chatbot in improving the mental wellbeing of health workers in Malawi during the COVID-19 pandemic: A randomized, controlled trial

We conducted a randomized, controlled trial (RCT) to investigate our hypothesis that the interactive chatbot, Vitalk, is more effective in improving mental wellbeing and resilience outcomes of health workers in Malawi than the passive use of Internet resources. For our 2-arm, 8-week, parallel RCT (ISRCTN Registry: trial ID ISRCTN16378480), we recruited participants from 8 professional cadres from public and private healthcare facilities. The treatment arm used Vitalk; the control arm received links to Internet resources. The research team was blinded to the assignment. Of 1,584 participants randomly assigned to the treatment and control arms, 215 participants in the treatment and 296 in the control group completed baseline and endline anxiety assessments. Six assessments provided outcome measures for: anxiety (GAD-7); depression (PHQ-9); burnout (OLBI); loneliness (ULCA); resilience (RS-14); and resilience-building activities. We analyzed effectiveness using mixed-effects linear models, effect size estimates, and reliable change in risk levels. Results support our hypothesis. Difference-in-differences estimators showed that Vitalk reduced: depression (-0.68 [95% CI -1.15 to -0.21]); anxiety (-0.44 [95% CI -0.88 to 0.01]); and burnout (-0.58 [95% CI -1.32 to 0.15]). Changes in resilience (1.47 [95% CI 0.05 to 2.88]) and resilience-building activities (1.22 [95% CI 0.56 to 1.87]) were significantly greater in the treatment group. Our RCT produced a medium effect size for the treatment and a small effect size for the control group. This is the first RCT of a mental health app for healthcare workers during the COVID-19 pandemic in Southern Africa combining multiple mental wellbeing outcomes and measuring resilience and resilience-building activities. A substantial number of participants could have benefited from mental health support (1 in 8 reported anxiety and depression; 3 in 4 suffered burnout; and 1 in 4 had low resilience). Such help is not readily available in Malawi. Vitalk has the potential to fill this gap.

Additive effects of adjunctive app-based interventions for mental disorders - A systematic review and meta-analysis of randomised controlled trials

Background

It is uncertain whether app-based interventions add value to existing mental health care.

Objective

To examine the incremental effects of app-based interventions when used as adjunct to mental health interventions.

Methods

We searched PubMed, PsycINFO, Scopus, Web of Science, and Cochrane Library databases on September 15th, 2023, for randomised controlled trials (RCTs) on mental health interventions with an adjunct app-based intervention compared to the same intervention-only arm for adults with mental disorders or respective clinically relevant symptomatology. We conducted meta-analyses on symptoms of different mental disorders at postintervention. PROSPERO, CRD42018098545.

Results

We identified 46 RCTs (4869 participants). Thirty-two adjunctive app-based interventions passively or actively monitored symptoms and behaviour, and in 13 interventions, the monitored data were sent to a therapist. We found additive effects on symptoms of depression (g = 0.17; 95 % CI 0.02 to 0.33; k = 7 comparisons), anxiety (g = 0.80; 95 % CI 0.06 to 1.54; k = 3), mania (g = 0.2; 95 % CI 0.02 to 0.38; k = 4), smoking cessation (g = 0.43; 95 % CI 0.29 to 0.58; k = 10), and alcohol use (g = 0.23; 95 % CI 0.08 to 0.39; k = 7). No significant effects were found on symptoms of depression within a bipolar disorder (g = -0.07; 95 % CI -0.37 to 0.23, k = 4) and eating disorders (g = -0.02; 95 % CI -0.44 to 0.4, k = 3). Studies on depression, mania, smoking, and alcohol use had a low heterogeneity between the trials. For other mental disorders, only single studies were identified. Only ten studies had a low risk of bias, and 25 studies reported insufficient statistical power.

Discussion

App-based interventions may be used to enhance mental health interventions to further reduce symptoms of depression, anxiety, mania, smoking, and alcohol use. However, the effects were small, except for anxiety, and limited due to study quality. Further high-quality research with larger sample sizes is warranted to better understand how app-based interventions can be most effectively combined with established interventions to improve outcomes.

Physical activity with person-centered guidance supported by a digital platform or with telephone follow-up for persons with chronic widespread pain: Health economic considerations along a randomized controlled trial

OBJECTIVES

The aim was to investigate the resource use and costs associated with the co-creation of a physical activity plan for persons with chronic widespread pain (CWP) followed by support through a digital platform, compared to telephone follow-up.

METHODS

In this 12-month cost comparison study following up results after a randomized controlled trial, individuals with CWP, aged 20-65 years, were recruited at primary healthcare units in Western Sweden. All participants developed a person-centered health-enhancing physical activity plan together with a physiotherapist. Participants were then randomized to either an intervention group (n  =  69) who had a follow-up visit after 2 weeks and was thereafter supported through a digital platform, or an active control group (n  =  70) that was followed up through one phone call after a month. Costs to the health system were salary costs for the time recorded by physiotherapists when delivering the interventions.

RESULTS

The reported time per person (2.8 h during the 12 months) corresponded to costs of SEK 958 (range: 746-1,517) for the initial visits and follow-up (both study groups), and an additional 2.5 h (corresponding to a mean SEK 833; range: 636-1,257) for the time spent in the digital platform to support the intervention group.

CONCLUSION

After co-creation of a physical activity plan, it was more costly to support persons through a digital platform, compared to telephone follow-up.

Refocusing of Attention on Positive Events Using Monitoring-Based Feedback and Microinterventions for Patients With Chronic Musculoskeletal Pain in the PerPAIN Randomized Controlled Trial: Protocol for a Microrandomized Trial

BACKGROUND

Chronic musculoskeletal pain (CMSP) affects between 13% and 47% of the population, with a global growth rate of 20.3% within the last 15 years, suggesting that there is a high need for effective treatments. Pain diaries have long been a common tool in nonpharmacological pain treatment for monitoring and providing feedback on patients' symptoms in daily life. More recently, positive refocusing techniques have come to be used, promoting pain-free episodes and positive outcomes rather than focusing on managing the pain.

OBJECTIVE

This study aims to evaluate the feasibility (ie, acceptability, intervention adherence, and fidelity) and initial signals of efficacy of the PerPAIN app, an ecological momentary intervention for patients with CMSP. The app comprises digitalized monitoring using the experience sampling method (ESM) and feedback. In addition, the patients receive 3 microinterventions targeted at refocusing of attention on positive events.

METHODS

In a microrandomized trial, we will recruit 35 patients with CMSP who will be offered the app for 12 weeks. Participants will be prompted to fill out 4 ESM monitoring questionnaires a day assessing information on their current context and the proximal outcome variables: absence of pain, positive mood, and subjective activity. Participants will be randomized daily and weekly to receive no feedback, verbal feedback, or visual feedback on proximal outcomes assessed by the ESM. In addition, the app will encourage participants to complete 3 microinterventions based on positive psychology and cognitive behavioral therapy techniques. These microinterventions are prompts to report joyful moments and everyday successes or to plan pleasant activities. After familiarizing themselves with each microintervention individually, participants will be randomized daily to receive 1 of the 3 exercises or none. We will assess whether the 2 feedback types and the 3 microinterventions increase proximal outcomes at the following time point. The microrandomized trial is part of the PerPAIN randomized controlled trial (German Clinical Trials Register DRKS00022792) investigating a personalized treatment approach to enhance treatment outcomes in CMSP.

RESULTS

Approval was granted by the Ethics Committee II of the University of Heidelberg on August 4, 2020. Recruitment for the microrandomized trial began in May 2021 and is ongoing at the time of submission. By October 10, 2022, a total of 24 participants had been enrolled in the microrandomized trial.

CONCLUSIONS

This trial will provide evidence on the feasibility of the PerPAIN app and the initial signals of efficacy of the different intervention components. In the next step, the intervention would need to be further refined and investigated in a definitive trial. This ecological momentary intervention presents a potential method for offering low-level accessible treatment to a wide range of people, which could have substantial implications for public health by reducing disease burden of chronic pain in the population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43376.

Psychological therapies delivered remotely for the management of chronic pain (excluding headache) in adults

BACKGROUND

Chronic pain (pain lasting three months or more) is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Common types (excluding headache) include back pain, fibromyalgia, and neuropathic pain. Access to traditional face-to-face therapies can be restricted by healthcare resources, geography, and cost. Remote technology-based delivery of psychological therapies has the potential to overcome treatment barriers. However, their therapeutic effectiveness compared to traditional delivery methods requires further investigation.

OBJECTIVES

To determine the benefits and harms of remotely-delivered psychological therapies compared to active control, waiting list, or treatment as usual for the management of chronic pain in adults.

SEARCH METHODS

We searched for randomised controlled trials (RCTs) in CENTRAL, MEDLINE, Embase, and PsycINFO to 29 June 2022. We also searched clinical trials registers and reference lists. We conducted a citation search of included trials to identify any further eligible trials.

SELECTION CRITERIA

We included RCTs in adults (≥ 18 years old) with chronic pain. Interventions included psychological therapies with recognisable psychotherapeutic content or based on psychological theory. Trials had to have delivered therapy remote from the therapist (e.g. Internet, smartphone application) and involve no more than 30% contact time with a clinician. Comparators included treatment as usual (including waiting-list controls) and active controls (e.g. education).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included 32 trials (4924 participants) in the analyses. Twenty-five studies delivered cognitive behavioural therapy (CBT) to participants, and seven delivered acceptance and commitment therapy (ACT). Participants had back pain, musculoskeletal pain, opioid-treated chronic pain, mixed chronic pain, hip or knee osteoarthritis, spinal cord injury, fibromyalgia, provoked vestibulodynia, or rheumatoid arthritis. We assessed 25 studies as having an unclear or high risk of bias for selective reporting. However, across studies overall, risk of bias was generally low. We downgraded evidence certainty for primary outcomes for inconsistency, imprecision, and study limitations. Certainty of evidence ranged from moderate to very low. Adverse events were inadequately reported or recorded across studies. We report results only for studies in CBT here. Cognitive behavioural therapy (CBT) versus treatment as usual (TAU) Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to TAU (standardised mean difference (SMD) -0.28, 95% confidence interval (CI) -0.39 to -0.16; 20 studies, 3206 participants; moderate-certainty evidence). Participants receiving CBT are probably more likely to achieve a 30% improvement in pain intensity compared to TAU (23% versus 11%; risk ratio (RR) 2.15, 95% CI 1.62 to 2.85; 5 studies, 1347 participants; moderate-certainty evidence). They may also be more likely to achieve a 50% improvement in pain intensity (6% versus 2%; RR 2.31, 95% CI 1.14 to 4.66; 4 studies, 1229 participants), but the evidence is of low certainty. At follow-up, there is likely little to no difference in pain intensity between CBT and TAU (SMD -0.04, 95% CI -0.17 to 0.09; 8 studies, 959 participants; moderate-certainty evidence). The evidence comparing CBT to TAU on achieving a 30% improvement in pain is very uncertain (40% versus 24%; RR 1.70, 95% CI 0.82 to 3.53; 1 study, 69 participants). No evidence was available regarding a 50% improvement in pain. Functional disability Immediately after treatment, CBT may demonstrate a small beneficial improvement compared to TAU (SMD -0.38, 95% CI -0.53 to -0.22; 14 studies, 2672 participants; low-certainty evidence). At follow-up, there is likely little to no difference between treatments (SMD -0.05, 95% CI -0.23 to 0.14; 3 studies, 461 participants; moderate-certainty evidence). Quality of life Immediately after treatment, CBT may not have resulted in a beneficial effect on quality of life compared to TAU, but the evidence is very uncertain (SMD -0.16, 95% CI -0.43 to 0.11; 7 studies, 1423 participants). There is likely little to no difference between CBT and TAU on quality of life at follow-up (SMD -0.16, 95% CI -0.37 to 0.05; 3 studies, 352 participants; moderate-certainty evidence). Adverse events Immediately after treatment, evidence about the number of people experiencing adverse events is very uncertain (34% in TAU versus 6% in CBT; RR 6.00, 95% CI 2.2 to 16.40; 1 study, 140 participants). No evidence was available at follow-up. Cognitive behavioural therapy (CBT) versus active control Pain intensity Immediately after treatment, CBT likely demonstrates a small beneficial effect compared to active control (SMD -0.28, 95% CI -0.52 to -0.04; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (mean difference (MD) 0.50, 95% CI -0.30 to 1.30; 1 study, 127 participants). No evidence was available for a 30% or 50% pain intensity improvement. Functional disability Immediately after treatment, there may be little to no difference between CBT and active control on functional disability (SMD -0.26, 95% CI -0.55 to 0.02; 2 studies, 189 participants; low-certainty evidence). The evidence at follow-up is very uncertain (MD 3.40, 95% CI -1.15 to 7.95; 1 study, 127 participants). Quality of life Immediately after treatment, there is likely little to no difference in CBT and active control (SMD -0.22, 95% CI -1.11 to 0.66; 3 studies, 261 participants; moderate-certainty evidence). The evidence at follow-up is very uncertain (MD 0.00, 95% CI -0.06 to 0.06; 1 study, 127 participants). Adverse events Immediately after treatment, the evidence comparing CBT to active control is very uncertain (2% versus 0%; RR 3.23, 95% CI 0.13 to 77.84; 1 study, 135 participants). No evidence was available at follow-up.

AUTHORS' CONCLUSIONS

Currently, evidence about remotely-delivered psychological therapies is largely limited to Internet-based delivery of CBT. We found evidence that remotely-delivered CBT has small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain. Benefits were not maintained at follow-up. Our appraisal of quality of life and adverse events outcomes post-treatment were limited by study numbers, evidence certainty, or both. We found limited research (mostly low to very low certainty) exploring other psychological therapies (i.e. ACT). More high-quality studies are needed to assess the broad translatability of psychological therapies to remote delivery, the different delivery technologies, treatment longevity, comparison with active control, and adverse events.

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.

Comparison of the effectiveness of eHealth self-management interventions for pain between oncological and musculoskeletal populations: a systematic review with narrative synthesis

OBJECTIVES

The aim of this systematic review is to compare the effectiveness of eHealth self-management interventions on pain intensity between oncological and musculoskeletal populations and to examine barriers and facilitators of the use of eHealth self-management tools.

CONTENT

In March 2021, a systematic search of the literature was conducted using the databases PubMed and Web of Science. Studies that investigated the effect of eHealth self-management interventions on pain intensity in an oncological and/or a musculoskeletal population were included.

SUMMARY

No study was found with a direct comparison of the two populations. Of the ten included studies, only one (musculoskeletal) found a significant interaction effect in favor of the eHealth program and three (musculoskeletal and breast cancer) showed a significant time-effect of the eHealth intervention. In both populations user-friendliness of the tool was considered as a facilitator, the length of the program and the lack of an in-person session as barrier. Due to the absence of a direct comparison, no conclusion can be made on how the effectiveness differs between both populations.

OUTLOOK

Further research should incorporate patient-experienced barriers and facilitators and there is a high need of studies making the direct comparison of the effect of an eHealth self-management intervention on pain intensity in an oncological vs. a MSK population.

e-Health Interventions Targeting Pain-Related Psychological Variables in Fibromyalgia: A Systematic Review

There is growing evidence to support the potential benefit of e-Health interventions targeting psychosocial outcomes and/or pain-related psychological variables for chronic pain conditions, including fibromyalgia syndrome (FMS). This systematic review aims at providing an in-depth description of the available e-Health psychological and/or multicomponent interventions for patients with FMS. Searches were made in PubMed, Cochrane, Web of Science, and PsycINFO up to 15 May 2023, finally including twenty-six articles. The quality of the included articles was medium-high (average quality assessment score of 77.1%). 50% of studies were randomized controlled trials (RCTs) (n = 13), and the majority of them focused exclusively on adult patients with FMS (n = 23) who were predominantly female. Four categories of e-Health modalities were identified: web-based (n = 19), mobile application (m-Health) (n = 3), virtual reality (VR) (n = 2), and video consulting (n = 2). Interventions were mainly based on the cognitive behavioral therapy (CBT) approach (n = 14) and mostly involved contact with a healthcare professional through different digital tools. Overall, a growing number of psychological and multicomponent interventions have been created and delivered using digital tools in the context of FMS, showing their potentiality for improving psychosocial outcomes and pain-related psychological variables. However, some digital tools resulted as underrepresented, and the literature on this topic appears highly heterogeneous precluding robust conclusions.

Long-term Use of Wearable Health Technology by Chronic Pain Patients

OBJECTIVES

People living with chronic pain may use wearable health technology (WHT) in conjunction with an expert-directed pain management program for up to 1 year. WHT use may be associated with improvements in key patient outcomes.

METHODS

A 12-month study of WHT use among people with chronic pain was conducted, consisting of iPhone and Apple Watch applications to measure movement, sleep, and self-reported pain. Clinical outcomes among 105 patients enrolled in a multidisciplinary pain program that included WHT use were compared with 146 patients in the same program but without WHT, and to 161 patients receiving medical pain management without WHT.

RESULTS

Participants used the WHT on average 143.0 (SD: 117.6) out of 365 days. Mixed-effects models revealed participants who used WHT had decreases in depression scores (-7.83, P <0.01) and prescribed morphine milligram equivalents (-21.55, P =0.04) over 1 year. Control groups also showed decreases in depression scores (-5.08, P =0.01; -5.68, P <0.01) and morphine milligram equivalents (-18.67, P =0.01; -10.99, ns). The estimated slope of change among the WHT was not statistically different than control groups.

DISCUSSION

Patients who used WHT as part of their pain management program demonstrated a willingness to do so for extended periods of time despite living with chronic pain and other comorbidities. Data trends suggest that WHT use may positively impact depression and prescribed medication. Additional research is warranted to investigate the potential of WHT to improve the negative consequences of chronic pain.

Operationalizing Engagement With an Interpretation Bias Smartphone App Intervention: Case Series

BACKGROUND

Engagement with mental health smartphone apps is an understudied but critical construct to understand in the pursuit of improved efficacy.

OBJECTIVE

This study aimed to examine engagement as a multidimensional construct for a novel app called HabitWorks. HabitWorks delivers a personalized interpretation bias intervention and includes various strategies to enhance engagement such as human support, personalization, and self-monitoring.

METHODS

We examined app use in a pilot study (n=31) and identified 5 patterns of behavioral engagement: consistently low, drop-off, adherent, high diary, and superuser.

RESULTS

We present a series of cases (5/31, 16%) from this trial to illustrate the patterns of behavioral engagement and cognitive and affective engagement for each case. With rich participant-level data, we emphasize the diverse engagement patterns and the necessity of studying engagement as a heterogeneous and multifaceted construct.

CONCLUSIONS

Our thorough idiographic exploration of engagement with HabitWorks provides an example of how to operationalize engagement for other mental health apps.

Effectiveness of a Fibromyalgia Online Nursing Consultation in the Quality of Life: A Randomized Controlled Trial

BACKGROUND

Aim: To evaluate the effectiveness of an online nursing consultation through the Internet platform Red Sinapsis (RS) in improving the perceived quality of life of patients with fibromyalgia (FM).

METHOD

Eighty patients with FM were randomized to an intervention group (n = 40) or control group (n= 40). The intervention group (IG) was monitored by a nursing specialist through the online platform RS while the control group (CG) received standard follow-up at the clinic. The Fibromyalgia Impact Questionnaire (FIQ) and 36-item Short-Form Health Survey (SF-36) were used at baseline, 6-month, and 12-month follow-up.

RESULTS

The IG showed a 65% improvement in the perception of their general state of health at 12 months into the study, compared with an improvement of 5.6% in the CG (p < .001). The IG also achieved better results for emotional status, with a maintained improvement throughout the study of more than 2 points in the anxiety variable (from 7.64 to 5.36), that remained constant in the CG. The depression variable also showed constant improvement over the 12 months of the study in the IG, rising from an average of 7.72 (standard deviation [SD] = 2.05) to 5.33 (SD = 1.65), while in the CG a slight deterioration was observed. In both cases, the difference in mood evolution was significant (p < .001).

CONCLUSIONS

Online nursing follow-up for people with fibromyalgia improves patients' perceived quality of life related to their welfare and emotional state. Fibromyalgia (FM) is among the diseases causing the highest rate of occupational disability in Spain. Fibromyalgia (FM) is a complex condition that causes pain, fatigue, non-refreshed sleep, mood disturbance and cognitive impairment.

User-Centered Design to Enhance mHealth Systems for Individuals With Dexterity Impairments: Accessibility and Usability Study

Background

Mobile health systems have been shown to be useful in supporting self-management by promoting adherence to schedules and longitudinal health interventions, especially in people with disabilities. The Interactive Mobile Health and Rehabilitation (iMHere) system was developed to empower people with disabilities and those with chronic conditions with supports needed for self-management and independent living. Since the first iteration of the iMHere 1.0 app, several studies have evaluated the accessibility and usability of the system. Potential opportunities to improve and simplify the user interface were identified, and the iMHere modules were redesigned accordingly.

Objective

In this study, we aim to evaluate the usability of the redesigned modules within the iMHere 1.0 app.

Methods

We evaluated the original and redesigned iMHere modules—MyMeds and SkinCare. The Purdue Pegboard Test was administered to assess the participants’ dexterity levels. Participants were then asked to perform a set of tasks using both the original and redesigned MyMeds and SkinCare modules to assess their efficiency and effectiveness. Usability was measured using the Telehealth Usability Questionnaire to evaluate 10 new accessibility features that were added to the redesigned app. Participants were also asked which version they preferred.

Results

In total, 24 participants with disabilities and varying degrees of dexterity impairments completed the entire study protocol. Participants displayed improved efficiency and effectiveness when using the redesigned modules compared with the original modules. The participants also reported improved usability and preferred the redesigned modules.

Conclusions

This study demonstrated that the iMHere system became more efficient, effective, and usable for individuals with dexterity impairments after redesigning it according to user-centered principles.

eHealth Interventions to Support Self-Management in People With Musculoskeletal Disorders, "eHealth: It's TIME"-A Scoping Review

OBJECTIVE

eHealth-mediated interventions have been proposed as one option to support self-management in those with musculoskeletal disorders (MSDs). This scoping review aimed to chart the evidence regarding eHealth modalities, musculoskeletal diagnosis, and outcomes of eHealth-mediated self-management support interventions in persons with MSDs and identify any gaps within the literature.

METHODS

Six electronic databases (MEDLINE, CINAHL, PsycINFO, Embase, Scopus, and the Cochrane Database of Systematic Reviews), 7 grey literature sources (eg, OpenGrey), and reference and citation lists of included studies were searched from database inception to July 2020. Published studies of adult participants with a MSD utilizing an eHealth intervention to support self-management were included. Studies were limited to those published in English. Two reviewers independently screened all studies. Data were extracted by 1 reviewer and reviewed by another reviewer.

RESULTS

After screening 3377 titles and abstracts followed by 176 full texts, 87 studies fulfilled the eligibility criteria. The majority were published in the last 5 years (n = 48; 55%), with almost one-third originating in the United States (n = 28; 32%). The most common eHealth modality type was internet based (n = 22; 35%), with almost one-half (n = 41; 47%) of the included studies involving participants with widespread musculoskeletal symptoms. The most commonly reported outcomes were related to body functions (ie, pain intensity) (n = 67; 45%), closely followed by activities and participation (ie, function) (n = 65; 44%), with environmental factors (ie, health care utilization) the least commonly reported (n = 17; 20%).

CONCLUSIONS

There is considerable variation within the eHealth-mediated self-management support intervention literature. Research is needed on the role of eHealth-mediated self-management support interventions across a broad range of MSDs to guide clinical practice.

IMPACT

This scoping review has identified gaps in the literature relating to specific eHealth modalities, musculoskeletal diagnoses, and health care utilization data, which should guide future research.

Technology-supported Acceptance and Commitment Therapy for chronic health conditions: A systematic review and meta-analysis

Chronic health conditions (CHCs) are common and associated with functional limitations. Acceptance and commitment therapy (ACT) shows promise in improving functioning, quality of life, and distress across several CHCs. The purpose of this study was to conduct a systematic review of technology-supported ACT for CHCs and perform a meta-analysis on functioning and ACT process outcomes. Multiple databases were systematically searched for randomized controlled trials. A total of 20 unique studies with 2,430 randomized participants were included. CHCs addressed in these studies were chronic pain (k = 9), obesity/overweight (k = 4), cancer (k = 3), hearing loss (k = 1), HIV (k = 1), multiple sclerosis (k = 1), and tinnitus (k = 1). Internet and telephone were the most used technology platforms. All studies included therapist contact with considerable heterogeneity between studies. Random effects meta-analyses found medium effect sizes showing technology-supported ACT outperformed comparator groups on measures of function at post-treatment (Hedges' g = -0.49; p = 0.002) and follow-up (Hedges' g = -0.52; p = 0.02), as well as ACT process outcomes at post-treatment (Hedges' g = 0.48; p < 0.001) and follow-up (Hedges' g = 0.44; p < 0.001). Technology-supported ACT shows promise for improving function and ACT process outcomes across a range of CHCs. Recommendations are provided to optimize technology-supported ACT for CHCs. PROSPERO registration number: CRD42020200230.

Presentation, Treatment, and Natural Course of Severe Symptoms of Urinary Tract Infections Measured by a Smartphone App: Observational and Feasibility Study

Background

Urinary tract infections (UTIs) are one of the most common conditions in women. Current information on the presentation, management, and natural course of the infection is based on paper diaries filled out and subsequently posted by patients.

Objective

The aim of this study is to explore the feasibility of a smartphone app to assess the natural course and management of UTIs.

Methods

A smartphone app was developed to collect data from study participants presenting with symptoms of UTI in general practice. After initial demographic and treatment information, symptom severity was recorded by the patient after a reminder on their smartphone, which occurred twice daily for a period of 7 days or until symptom resolution.

Results

A total of 181 women aged 18-76 years downloaded the smartphone app. The duration of symptoms was determined from the results of 178 participants. All patients submitted a urine sample, most patients were prescribed an antibiotic (163/181, 90.1%), and 38.7% (70/181) of the patients had a positive culture. Moderately bad or worse symptoms lasted a mean of 3.8 (SD 3.2; median 4) days, and 70.2% (125/178) of the patients indicated that they were cured on day 4 after consultation. This compares with other research assessing symptom duration and management of UTIs using paper diaries. Patients were very positive about the usability of the smartphone app and often found the reminders supportive. On the basis of the feedback and the analysis of the data, some suggestions for improvement were made.

Conclusions

Smartphone diaries for symptom scores over the course of infections are an efficient and acceptable means of collecting data in research.

Self-management for chronic widespread pain including fibromyalgia: A systematic review and meta-analysis

BACKGROUND

Chronic widespread pain (CWP) including fibromyalgia has a prevalence of up to 15% and is associated with substantial morbidity. Supporting psychosocial and behavioural self-management is increasingly important for CWP, as pharmacological interventions show limited benefit. We systematically reviewed the effectiveness of interventions applying self-management principles for CWP including fibromyalgia.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Central Register of Controlled Trials and the WHO International Clinical Trials Registry were searched for studies reporting randomised controlled trials of interventions adhering to self-management principles for CWP including fibromyalgia. Primary outcomes included physical function and pain intensity. Where data were sufficient, meta-analysis was conducted using a random effects model. Studies were narratively reviewed where meta-analysis could not be conducted Evidence quality was rated using GRADE (Grading of Recommendations, Assessment, Development and Evaluations) (PROSPERO-CRD42018099212).

RESULTS

Thirty-nine completed studies were included. Despite some variability in studies narratively reviewed, in studies meta-analysed self-management interventions improved physical function in the short-term, post-treatment to 3 months (SMD 0.42, 95% CI 0.20, 0.64) and long-term, post 6 months (SMD 0.36, 95% CI 0.20, 0.53), compared to no treatment/usual care controls. Studies reporting on pain narratively had greater variability, however, those studies meta-analysed showed self-management interventions reduced pain in the short-term (SMD -0.49, 95% CI -0.70, -0.27) and long-term (SMD -0.38, 95% CI -0.58, -0.19) compared to no treatment/usual care. There were few differences in physical function and pain when self-management interventions were compared to active interventions. The quality of the evidence was rated as low.

CONCLUSION

Reviewed studies suggest self-management interventions can be effective in improving physical function and reducing pain in the short and long-term for CWP including fibromyalgia. However, the quality of evidence was low. Future research should address quality issues whilst making greater use of theory and patient involvement to understand reported variability.

mHealth Interventions to Support Prescription Opioid Tapering in Patients With Chronic Pain: Qualitative Study of Patients' Perspectives

BACKGROUND

Patients with chronic pain who are tapering prescription opioids report a need for greater support for coping with symptoms of pain and withdrawal. Mobile health (mHealth) technologies (SMS text messaging- or app-based) have the potential to provide patients with educational, emotional, and motivational support for opioid tapering beyond what is offered by their health care provider. However, it is not known whether patients with chronic pain who are tapering opioids would be willing or able to engage with technology-based support.

OBJECTIVE

This study aims to examine patients' use of mobile technologies in health care, interest in using mHealth support, preferences for the form and content of mHealth support, and potential barriers to and facilitators of engagement with mHealth support for opioid tapering.

METHODS

A total of 21 patients (11 women and 10 men; age range 29-83 years) with chronic noncancer pain on long-term opioid therapy who had recently initiated a voluntary opioid taper were recruited from primary and tertiary care clinics in metropolitan and regional Australia for a larger study of patients' experiences of opioid tapering. Participants had been taking prescription opioids for a mean duration of 13 (SD 9.6; range 0.25-30) years at the time of the study. Survey items characterized participants' typical mobile phone use and level of interest in mobile technology-based support for opioid tapering. Semistructured interviews further explored patients' use of mobile technologies and their interest in, preferences for, and perspectives on potential barriers to and facilitators of engagement with mHealth support for opioid tapering. Two researchers collaborated to conduct a thematic analysis of the interview data.

RESULTS

All participants reported owning and using a mobile phone, and most (17/21, 81%) participants reported using mobile apps. The majority of participants expressed interest in SMS text messaging-based (17/21, 81%) and app-based (15/21, 71%) support for opioid tapering. Participants expected that messages delivering both informational and socioemotional support would be helpful. Participants expected that access to technology, mobile reception, internet connectivity, vision impairment, and low self-efficacy for using apps may be barriers to user engagement. Patients expected that continuity of care from their health care provider, flexible message dosing, responsivity, and familiarity with pain self-management strategies would increase user engagement.

CONCLUSIONS

The results of this study indicate that patients with chronic noncancer pain may be willing to engage with SMS text messaging-based and app-based mHealth interventions to support opioid tapering. However, the feasibility and acceptability of these interventions may depend on how patients' preferences for functionality, content, and design are addressed.

Feasibility randomised controlled trial comparing TRAK-ACL digital rehabilitation intervention plus treatment as usual versus treatment as usual for patients following anterior cruciate ligament reconstruction

Objectives

To evaluate the feasibility of trialling taxonomy for the rehabilitation of knee conditions—ACL (TRAK-ACL), a digital health intervention that provides health information, personalised exercise plans and remote clinical support combined with treatment as usual (TAU), for people following ACL reconstruction.

Methods

The study design was a two-arm parallel randomised controlled trial (RCT). Eligible participants were English-speaking adults who had undergone ACL reconstruction within the last 12 weeks, had access to the internet and could provide informed consent. Recruitment took place at three sites in the UK. TRAK-ACL intervention was an interactive website informed by behaviour change technique combined with TAU. The comparator was TAU. Outcomes were: recruitment and retention; completeness of outcome measures at follow-up; fidelity of intervention delivery and engagement with the intervention. Individuals were randomised using a computer-generated random number sequence. Blinded assessors allocated groups and collected outcome measures.

Results

Fifty-nine people were assessed for eligibility at two of the participating sites, and 51 were randomised; 26 were allocated to TRAK-ACL and 25 to TAU. Follow-up data were collected on 44 and 40 participants at 3 and 6 months, respectively. All outcome measures were completed fully at 6 months except the Client Service Receipt Inventory. Two patients in each arm did not receive the treatment they were randomised to. Engagement with TRAK-ACL intervention was a median of 5 logins (IQR 3–13 logins), over 18 weeks (SD 12.2 weeks).

Conclusion

TRAK-ACL would be suitable for evaluation of effectiveness in a fully powered RCT.

Smartphone Applications Designed to Improve Older People's Chronic Pain Management: An Integrated Systematic Review

(1) Background: Older people’s chronic pain is often not well managed because of fears of side-effects and under-reporting. Telehealth interventions, in the form of smartphone applications, are attracting much interest in the management of chronic diseases, with new and evolving approaches in response to current population demographics. However, the extent to which telehealth interventions may be used to promote and effect the self-management of chronic pain is not established. (2) Aim: To provide an objective review of the existing quantitative and qualitative evidence pertaining to the benefits of smartphone applications for the management of chronic pain in older people. (3) Methods: A literature search was undertaken using PubMed, Medline, CINAHL, Embase, PsychINFO, the Cochrane database, Science Direct and references of retrieved articles. The data were independently extracted by two reviewers from the original reports. (4) Results: This integrative systematic review identified 10 articles considering smartphone applications related to self-management of chronic pain among older adults. (5) Conclusions: It is important for future research to not only examine the effects of smartphone initiatives, but also to compare their safety, acceptability, efficacy and cost–benefit ratio in relation to existing treatment modalities.

An Interactive Pain Application (MServ) Improves Postoperative Pain Management

Background

Most patients have moderate or severe pain after surgery. Opioids are the cornerstone of treating severe pain after surgery but cause problems when continued long after discharge. We investigated the efficacy of multifunction pain management software (MServ) in improving postoperative pain control and reducing opioid prescription at discharge.

Methods

We recruited 234 patients to a prospective cohort study into sequential groups in a nonrandomised manner, one day after major thoracic or urological surgery. Group 1 received standard care (SC, n = 102), group 2 were given a multifunctional device that fed back to the nursing staff alone (DN, n = 66), and group 3 were given the same device that fed back to both the nursing staff and the acute pain team (DNPT, n = 66). Patient-reported pain scores at 24 and 48 hours and patient-reported time in severe pain, medications, and satisfaction were recorded on trial discharge. Findings. Odds of having poor pain control (>1 on 0–4 pain scale) were calculated between standard care (SC) and device groups (DN and DNPT). Patients with a device were significantly less likely to have poor pain control at 24 hours (OR 0.45, 95% CI 0.25, 0.81) and to report time in severe pain at 48 hours (OR 0.62, 95% CI 0.47–0.80). Patients with a device were three times less likely to be prescribed strong opioids on discharge (OR 0.35, 95% CI 0.13 to 0.95). Interpretation. Using an mHealth device designed for pain management, rather than standard care, reduced the incidence of poor pain control in the postoperative period and reduced opioid prescription on discharge from hospital.

Barriers Associated with the Implementation of Homework in Youth Mental Health Treatment and Potential Mobile Health Solutions

BACKGROUND

Homework, or between-session practice of skills learned during therapy, is integral to effective youth mental health TREATMENTS. However, homework is often under-utilized by providers and patients due to many barriers, which might be mitigated via mHealth solutions.

METHODS

Semi-structured qualitative interviews were conducted with nationally certified trainers in Trauma Focused Cognitive Behavioral Therapy (TF-CBT; n=21) and youth TF-CBT patients ages 8-17 (n=15) and their caregivers (n=12) to examine barriers to the successful implementation of homework in youth mental health treatment and potential mHealth solutions to those barriers.

RESULTS

The results indicated that many providers struggle to consistently develop, assign, and assess homework exercises with their patients. Patients are often difficult to engage and either avoid or have difficulty remembering to practice exercises, especially given their busy/chaotic home lives. Trainers and families had positive views and useful suggestions for mHealth solutions to these barriers in terms of functionality (e.g., reminders, tracking, pre-made homework exercises, rewards) and user interface (e.g., easy navigation, clear instructions, engaging activities).

CONCLUSIONS

This study adds to the literature on homework barriers and potential mHealth solutions to those barriers, which is largely based on recommendations from experts in the field. The results aligned well with this literature, providing additional support for existing recommendations, particularly as they relate to treatment with youth and caregivers.

ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain-A Pilot Trial

BACKGROUND

Acceptance and commitment therapy (ACT) is a behavioral health intervention with strong empirical support for chronic pain but, to date, widespread dissemination is limited. Digital solutions improve access to care and can be integrated into patients' everyday lives.

OBJECTIVE

ACTsmart, a guided smartphone-delivered ACT intervention, was developed to improve the accessibility of an evidence-based behavioral treatment for chronic pain. In the present study, we evaluated the preliminary efficacy of ACTsmart in adults with chronic pain.

METHODS

The study was an open-label pilot trial. The treatment lasted for 8 weeks, and participants completed all outcome measures at pretreatment and posttreatment and at 3-, 6-, and 12-month follow-ups, with weekly assessments of selected measures during treatment. The primary outcome was pain interference. The secondary outcomes were psychological flexibility, values, insomnia, anxiety, depressive symptoms, health-related quality of life, and pain intensity. All outcomes were analyzed using linear mixed-effects models.

RESULTS

The sample consisted of 34 adults (88% women) with long-standing chronic pain (M=20.4 years, SD=11.7). Compliance to treatment was high, and at the end of treatment, we observed a significant improvement in the primary outcome of pain interference (d = -1.01). All secondary outcomes significantly improved from pretreatment to posttreatment with small to large effect sizes. Improvements were maintained throughout 12 months of follow-up.

CONCLUSION

The results of this pilot study provide preliminary support for ACTsmart as an accessible and effective behavioral health treatment for adults with chronic pain and warrant a randomized controlled trial to further evaluate the efficacy of the intervention.

Telehealth in the rehabilitation of female pelvic floor dysfunction: a systematic literature review

Introduction and hypothesis

The pandemic caused by coronavirus disease 2019 (COVID-19) increased the awareness and efforts to provide care from distance using information technologies. We reviewed the literature about the practice and effectiveness of the rehabilitation of the female pelvic floor dysfunction via telehealth regarding symptomatology and quality of life and function of pelvic floor muscles (PFM).

Methods

A bibliographic review was carried out in May 2020 in the databases: Embase, Medline/PubMed, LILACS and PEDro. A total of 705 articles were reviewed after the removal of duplicates. The methodological quality of the articles was evaluated by the PEDro scale. Two authors performed data extraction into a standardized spreadsheet.

Results

Four studies were included, two being randomized controlled trials. Among the RCTs, only one compared telehealth with face-to-face treatment; the second one compared telehealth with postal treatment. The other two studies are follow-up and cost analysis reports on telehealth versus postal evaluation. Data showed that women who received the intervention remotely presented significant improvement in their symptoms, such as reducing the number of incontinence episodes and voiding frequency, improving PFM strength and improving quality of life compared to women who had the face-to-face treatment.

Conclusions

Telehealth promoted a significant improvement in urinary symptoms, PFM function and quality of life. Telehealth is still emerging, and more studies are needed to draw more conclusions. The recommendations of the governmental authorities, physical therapy councils and corresponding associations of each country also need to be considered.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00192-020-04588-8.

Just-in-the-Moment Adaptive Interventions (JITAI): A Meta-Analytical Review

A just-in-time, adaptive intervention (JITAI) is an emerging type of intervention that provides tailored support at the exact time of need. It does so using enabling new technologies (e.g., mobile phones, sensors) that capture the changing states of individuals. Extracting effect sizes of primary outcomes produced by 33 empirical studies that used JITAIs, we found moderate to large effect sizes of JITAI treatments compared to (1) waitlist-control conditions (k = 9), Hedges's g = 1.65 and (2) non-JITAI treatments (k = 21), g = 0.89. Also, participants of JITAI interventions showed significant changes (k = 13) in the positive direction (g = 0.79). A series of sensitivity tests suggested that those effects persist. Those effects also persist despite differences in the behaviors of interests (e.g., blood glucose control, recovering alcoholics), duration of the treatments, and participants' age. Two aspects of tailoring, namely: (1) tailoring to what (i.e., both people's previous behavioral patterns and their current need states; with these effects additive) and (2) approach to tailoring (i.e., both using a human agent and an algorithm to decide tailored feedback; with these effects additive), are significantly associated with greater JITAI efficacy.

Digital Self-Management in Support of Patients Living With Chronic Pain: Feasibility Pilot Study

BACKGROUND

Chronic pain can be complex and taxing to live with, and treatment and support require a multicomponent approach, which may not always be offered or available. Smartphones, tablets, and personal computers are already incorporated into patients' daily lives, and therefore, they can be used to communicate, educate, and support self-management. Although some web-based self-management interventions exist, research examining the evidence and effect of digital solutions supporting self-management for patients living with chronic pain is limited, findings are inconclusive, and new innovative ideas and solutions are needed.

OBJECTIVE

This feasibility pilot study aimed to explore the system use, perceived usefulness, ease of use, and preliminary effects of EPIO, an app-based cognitive-behavioral pain self-management intervention program for patients living with chronic pain.

METHODS

The EPIO intervention was delivered in a blended-care model containing (1) one face-to-face introduction session, (2) nine cognitive behavior-based pain self-management modules, delivered in an app-based format for smartphones or tablets, and (3) one follow-up phone call at 2 to 3 weeks after the introduction session. Patients living with chronic pain (N=50) completed pre-post outcome measures at baseline and 3 months after the introduction session, with registration of system use (ie, log data) until 6 months. The use, perceived usefulness, and ease of use of the EPIO program were examined through system use data, as well as a study-specific use/usability questionnaire and the System Usability Scale (SUS). Outcome measures to test feasibility of use and estimate preliminary effects included the Brief Pain Inventory, health-related quality of life (HRQoL) scale, Hospital Anxiety and Depression Scale, Self-Regulatory Fatigue scale, Pain Catastrophizing Scale, and Chronic Pain Acceptance Questionnaire.

RESULTS

Participants (N=50) had a median age of 52 years (range 29-74 years) at inclusion and were mainly female (40/50, 80%). Thirty-one participants completed at least six of the nine modules within the 3-month study period (62% completion rate). Forty-five participants completed outcome measures at 3 months, and the EPIO program was rated as useful (ie, "totally agree" or "agree"; 39/45, 87%) and easy to use (42/45, 93%), and as having easily understandable exercises (44/45, 98%). The average overall system usability (SUS) score was 85.7, indicating grade A and excellent system usability. Preliminary psychosocial outcome measure estimates showed primarily nonsignificant pre-post intervention improvements at 3 months, but with significant positive effects related to some aspects of HRQoL (bodily pain, P=.02 and change, P=.049).

CONCLUSIONS

 Digital self-management intervention programs may be of use and support for patients living with chronic pain. In this feasibility study, EPIO showed an acceptable program completion rate and was rated as useful and easy to use, with excellent user satisfaction. Program optimization and efficacy testing in a large-scale randomized controlled trial are warranted and in progress.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Determining Perceptions to Electronically-Delivered, Personally-Adaptive, Multimedia Exercise Prompts for Middle-Age Adults

Due to high interaction rates, smart devices are being utilized for mobile health (mHealth) interventions. Multimedia capabilities may be leveraged to improve mHealth exercise interventions. Our purpose was to explore individuals' perceptions of multimedia exercise prompts tailored to their immediate mental/physical states. Using electronic surveys, respondents provided in-the-moment ratings of emotional state, energy, fatigue, physical discomfort, and thirst, with higher scores reflecting a higher "readiness to exercise" (i.e., if a person is currently in a pleasant mood with high energy and low discomfort, he/she is likely to have a greater capacity for a larger dose of exercise). They were then provided with an exercise prompt designed to match their readiness to exercise, demonstrated via text and graphic interchange format (GIF) showing a research member completing the recommended activity. Survey data regarding GIF quality, self-efficacy, and methodological feedback were then collected and analyzed using a combination of parametric statistics and thematic analysis of open-ended feedback. Respondents (N=204; 47±10 years; BMI 29±6 kg/m2) indicated GIFs loaded quickly (5.29±1.2, scale 0-6), were clear (5.36±1.1), and easily understandable (5.43±1.1). High task self-efficacy scores (9.34±1.62, scale 0-10) and statistically significant differences in coping self-efficacy (i.e., how well a person would be able to complete the recommended activity when feeling mentally/physically worse or better; F=3.229, p<.01) were found. Five themes relating to the exercise prompt were noted: improve attractiveness, limiting factors, exercise clarification, liked/understandable/doable, and disliked/unwilling to complete. Further refinement of these methods is warranted prior to using multimedia prompts to elicit actual exercise performance.

An opportunity for patient-centered care: Results from a secondary analysis of sex- and gender-based data in mobile health trials for chronic medical conditions

Traditional medical practice has suffered from male bias, which can lead to sub-optimal treatment options for female patients and increase the incidence of severe side-effects in this population. Mobile health applications, mHealth apps, represent one essential component of the shift towards consumer-centered self-administered individualized health. To prevent sex-specific bias it is important that trials consider sex and gender when developing mHealth apps. We evaluated the inclusion and reporting of sex and gender at all levels in mHealth randomized controlled trials (RCTs). To this end, we conducted a secondary analysis of a large study database addressing the effectiveness of app interventions on clinical outcomes in patients with chronic medical conditions. We followed the 5 steps described in the framework by Arksey and O'Malley and the guidelines of the PRISMA-ScR. Of the 72 app-based RCTs which reported information about sex overall, 62 included individuals of both sexes. The concept of gender was not addressed in any of the studies. The consideration of sex aspects in the design, execution and reporting of mHealth RCTs was minimal or absent. To adequately address the health and preventative needs of the mHealth user population, sex and gender should be systematically included in the research, development and evaluation of mHealth applications.

Can Acceptance, Mindfulness, and Self-Compassion Be Learned by Smartphone Apps? A Systematic and Meta-Analytic Review of Randomized Controlled Trials

The potential health benefits of acceptance, mindfulness, and self-compassion are well-documented. However, interventions that teach these principles typically rely on face-to-face delivery, which can limit their dissemination. Delivering these interventions through smartphone apps could help overcome this. This meta-analysis examined whether principles of acceptance, mindfulness, and self-compassion can be learned through smartphone apps. Twenty-seven randomized controlled trials were included. Smartphone apps that included acceptance and/or mindfulness components resulted in significantly higher levels of acceptance/mindfulness than comparison conditions (k = 33; g = 0.29; 95% CI = 0.17, 0.41). These effects were moderated by the type of comparison and whether reminders to engage were offered. Smartphone apps also resulted in significantly lower levels of psychological distress than comparisons (k = 22; g = -0.32; 95% CI = -0.48, -0.16). Meta-regression revealed a negative relationship between the effect sizes for mindfulness/acceptance and the effect sizes for distress. Smartphone apps produced significantly greater increases in self-compassion than comparisons (k = 9; g = 0.31; 95% CI = 0.07, 0.56), although the quality of RCTs in this analysis was poor. Findings suggest that principles of acceptance, mindfulness, and self-compassion may be learned through cheap, easily accessible, and low-intensity interventions delivered via smartphone apps. However, the quality of available evidence is poor, as low risk of bias was noted in few trials (18%) and the observed effects were likely explained by a digital placebo.

Apps for pain self-management of older people's arthritic pain, one size doesn't fit all: A qualitative study

Introduction Arthritic pain is a major cause of illness and disability among older people. People living with arthritic pain carry out self-management activities to adequately manage their pain. As the trend of smartphone uptake continues to rise among older people, there are opportunities to explore the role of these devices in helping older people better manage their pain. Aim: To explore the attitudes and experiences of older people with chronic arthritic pain towards using an app for their pain selfmanagement. Methods A qualitative design using semi-structured interviews with community-dwelling older Australians living with arthritic pain (n = 16). Data was analyzed using thematic analysis. Results Four themes emerged from the data: (1) Apps are valuable self-management tool, but they do have the potential for harm; (2) A pain self-management app needs to strictly align with the user's needs; (3) Clinician's involvement is crucial when integrating an app into older people's pain selfmanagement regime; and (4) pain self-management app must be designed with enduser in mind. In addition, suggestions on how to make an app more useful and userfriendly were offered by the participants. Discussion While pain self-management apps have the potential to assist older people in their pain self-management process, this modality is not of interest to all older people. Adaptable apps that offer clinician input may be best placed to offer individual level relevance to older users. Future pain selfmanagement app development endeavors should adopt a co-design approach where older people are involved through all stages of design and development.

Assessing Real-Time Moderation for Developing Adaptive Mobile Health Interventions for Medical Interns: Micro-Randomized Trial

Background

Individuals in stressful work environments often experience mental health issues, such as depression. Reducing depression rates is difficult because of persistently stressful work environments and inadequate time or resources to access traditional mental health care services. Mobile health (mHealth) interventions provide an opportunity to deliver real-time interventions in the real world. In addition, the delivery times of interventions can be based on real-time data collected with a mobile device. To date, data and analyses informing the timing of delivery of mHealth interventions are generally lacking.

Objective

This study aimed to investigate when to provide mHealth interventions to individuals in stressful work environments to improve their behavior and mental health. The mHealth interventions targeted 3 categories of behavior: mood, activity, and sleep. The interventions aimed to improve 3 different outcomes: weekly mood (assessed through a daily survey), weekly step count, and weekly sleep time. We explored when these interventions were most effective, based on previous mood, step, and sleep scores.

Methods

We conducted a 6-month micro-randomized trial on 1565 medical interns. Medical internship, during the first year of physician residency training, is highly stressful, resulting in depression rates several folds higher than those of the general population. Every week, interns were randomly assigned to receive push notifications related to a particular category (mood, activity, sleep, or no notifications). Every day, we collected interns’ daily mood valence, sleep, and step data. We assessed the causal effect moderation by the previous week’s mood, steps, and sleep. Specifically, we examined changes in the effect of notifications containing mood, activity, and sleep messages based on the previous week’s mood, step, and sleep scores. Moderation was assessed with a weighted and centered least-squares estimator.

Results

We found that the previous week’s mood negatively moderated the effect of notifications on the current week’s mood with an estimated moderation of −0.052 (P=.001). That is, notifications had a better impact on mood when the studied interns had a low mood in the previous week. Similarly, we found that the previous week’s step count negatively moderated the effect of activity notifications on the current week’s step count, with an estimated moderation of −0.039 (P=.01) and that the previous week’s sleep negatively moderated the effect of sleep notifications on the current week’s sleep with an estimated moderation of −0.075 (P<.001). For all three of these moderators, we estimated that the treatment effect was positive (beneficial) when the moderator was low, and negative (harmful) when the moderator was high.

Conclusions

These findings suggest that an individual’s current state meaningfully influences their receptivity to mHealth interventions for mental health. Timing interventions to match an individual’s state may be critical to maximizing the efficacy of interventions.

Trial Registration

ClinicalTrials.gov NCT03972293; http://clinicaltrials.gov/ct2/show/NCT03972293

Improving chronic pain management with eHealth and mHealth: study protocol for a randomised controlled trial

INTRODUCTION

Chronic pain has become a matter of public health concern due to its high prevalence and because public costs associated with treatment and disability increase each year. Research suggests that limitations in the traditional assessment of chronic pain patients limit the effectiveness of current medical treatments. The use of technology might serve change patient traditional monitoring into ecological momentary assessments, which might be visualised by physicians live. This study describes a randomised control trial designed to test the utility of a technology-based solution for pain telemonitoring consisting of a smartphone app for patients and a web application for physicians. The goal of this study will be to explore whether this combination of eHealth and mHealth improves the effectiveness of existing pain treatments.

METHODS AND ANALYSIS

Participants will be 250 patients randomly assigned to one of these two conditions: treatment-as-usual (TAU) and TAU +app+ web. All participants will receive the usual treatment for their pain. Only the TAU +app+ web group use Pain Monitor app, which generates alarms that are sent to the physicians in the face of previously established undesired events. Physicians will be able to monitor app reports using a web application, which might result in an adjustment of treatment. We anticipate that the use of Pain Monitor plus the therapist web will result in a reduction of pain intensity and side effects of the medication. Improvements on secondary outcomes, namely fatigue, mood, pain interference, rescue medication use and quality of life, are also expected. Mixed repeated-measure multivariate analyses of variances will be conducted to investigate whether there are differences between preassessment and postassessment scores as a function of the experimental condition.

ETHICS AND DISSEMINATION

Ethical approval from the Hospital General Universitari de Castellon was obtained. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03606265.

A randomized controlled trial evaluating the effectiveness of an acceptance and commitment therapy-based bibliotherapy intervention among adults living with chronic pain

Background: Chronic pain has a significant impact on the physical and psychological functioning of those living with this condition. It is now recognized that acceptance and commitment therapy (ACT) is an effective intervention in managing chronic pain; however, several barriers limit its accessibility.

Aims: The current study aimed to evaluate the effectiveness of an 8-week bibliotherapy-type self-administered psychological intervention with minimal therapeutic contact, based on ACT, in the management of chronic pain.

Methods: This was a randomized controlled trial with three measurement periods (pretest, posttest, and 3 months after the intervention; ClinicalTrials.gov Identifier: NCT03924687). A total of 140 adults with chronic pain were randomly assigned to an ACT self-help condition or a wait-list control condition.

Results: Two-way repeated measures analysis of variance (ANOVA) models showed statistically significant differences between pretest and posttest in terms of pain-related disability (main variable), depression (secondary variable), pain-related acceptance, and psychological inflexibility (d = 0.46–0.88) in favor of the ACT self-help condition. At the 3-month follow-up, these differences were maintained and nearly 54% of participants reported an overall improvement of their physical and mental health.

Conclusion: These results suggest that a psychological intervention self-administered through ACT bibliotherapy with minimal therapeutic support can improve the physical and emotional functioning of adults from the community who live with chronic pain.

Mobile Health Apps for Self-Management of Rheumatic and Musculoskeletal Diseases: Systematic Literature Review

BACKGROUND

Although the increasing availability of mobile health (mHealth) apps may enable people with rheumatic and musculoskeletal diseases (RMDs) to better self-manage their health, there is a general lack of evidence on ways to ensure appropriate development and evaluation of apps.

OBJECTIVE

This study aimed to obtain an overview on existing mHealth apps for self-management in patients with RMDs, focusing on content and development methods.

METHODS

A search was performed up to December 2017 across 5 databases. For each publication relevant to an app for RMDs, information on the disease, purpose, content, and development strategies was extracted and qualitatively assessed.

RESULTS

Of 562 abstracts, 32 were included in the analysis. Of these 32 abstracts, 11 (34%) referred to an app linked to a connected device. Most of the apps targeted rheumatoid arthritis (11/32, 34%). The top three aspects addressed by the apps were pain (23/32, 71%), fatigue (15/32, 47%), and physical activity (15/32, 47%). The development process of the apps was described in 84% (27/32) of the articles and was of low to moderate quality in most of the cases. Despite most of the articles having been published within the past two years, only 5 apps were still commercially available at the time of our search. Moreover, only very few studies showed improvement of RMD outcome measures.

CONCLUSIONS

The development process of most apps was of low or moderate quality in many studies. Owing to the increasing RMD patients' willingness to use mHealth apps for self-management, optimal standards and quality assurance of new apps are mandatory.

Multi-disciplinary interventions for chronic pain involving education: A systematic review

BACKGROUND

There have been growing recommendations to include education in multi-disciplinary interventions targeting chronic pain management. However, effects of this strategy on short- and long-term self-management of chronic pain, remain largely unexplored.

OBJECTIVES

1. To provide an updated overview of studies that report on the impact of patient education in multi-disciplinary interventions, on self-management of chronic pain; 2. To explore associations between education and chronic pain self-management techniques; and 3. To identify the format and duration of suitable chronic pain interventions targeted at patient self-management.

METHODS

Design: Narrative systematic literature review of randomised or controlled study designs. Data Sources: PubMed, CINAHL, EMBASE, PsycINFO. Participants: Adult patients with chronic pain of any aetiology participating in multi-disciplinary programs that included education. Main outcome measures: Assessments of level of pain, function, quality of life, self-efficacy, self-management, and any other relevant assessments. Study Appraisal and Synthesis Methods: PRISMA guidelines, Cochrane Risk of Bias tool, and TIDieR model.

RESULTS

Database searching identified 485 potential papers. After removal of duplicates, and irrelevant articles by title and abstract, 120 full-text articles were reviewed and 27 studies were included in this systematic review. Studies were predominantly from the United States (n = 8; 29.6%). Over one hundred outcome measures were identified across all studies, with significant variation also observed in terms of how chronic pain duration was defined, and how education was delivered to participants. Overall, positive benefits of education were reported.

CONCLUSIONS

Education, as part of multi-disciplinary programs, is likely to improve self-management and self-efficacy in people with chronic pain of any aetiology. Heterogeneity in terms of: chronic pain duration; educational resources; healthcare professionals; and outcome measures, were identified as limitations. Further research, in the form of Randomised Controlled Trials addressing these limitations, is recommended.

Social Cognitive Theories and Electronic Health Design: Scoping Review

Background

There are several social cognitive theories (SCTs) and models that support platform design in electronic health (eHealth) promotion trials. The rationale for this scoping review was to determine how social design features (informational aid, expressive support, gaming, and tailored content) are used to promote self-efficacy, engagement, knowledge, and behavior change.

Objective

This study aimed to review a broad spectrum of digital health interventions in the literature seeking trials that use SCTs for the design of eHealth applications.

Methods

The author conducted a systematic scoping review of 161 Web-based health interventions from published randomized clinical trials using 1 or more tools to address the social cognitive determinants in their website design from January 2006 to April 2016. An iterative approach was used in the selection of studies and data extraction. The studies were analyzed for quality and coded for type of social design features employed.

Results

Expressive interaction tools were found in 48.6% (54/111) of studies categorized as a strong recommendation by the Joanna Briggs Institute criteria. Overall, less than half of the studies addressed participant social support and motivational needs (43.8%). The vast majority of studies (100%) relied on the use of the Web for delivery of informational aid and tailored content for the individual participant (75.9%).

Conclusions

This review fills a research gap by linking social theory to Web strategy to improve the impact and sustainability of eHealth interventions. A Digital Health Intervention Model was developed to provide a framework to enhance future Web-based health intervention design and execution.

An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis

BACKGROUND

Electronic health (eHealth) is the use of information and communication technology in the context of health care and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency with which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities.

OBJECTIVE

The aim of this systematic review with a network meta-analysis (NMA) is to compare the effectiveness of eHealth modalities in the context of chronic pain.

METHODS

Randomized controlled trials (N>20 per arm) that investigated interventions for adults with chronic pain, delivered via an eHealth modality, were included. Included studies were categorized into their primary node of delivery. Data were extracted on the primary outcome, pain interference, and secondary outcomes, pain severity, psychological distress, and health-related quality of life. Pairwise meta-analyses were undertaken where possible, and an NMA was conducted to generate indirect comparisons and rankings of modalities for reducing pain interference.

RESULTS

The search returned 18,470 studies with 18,349 being excluded (duplicates=2310; title and abstract=16,039). Of the remaining papers, 30 studies with 5394 randomized participants were included in the review. Rankings tentatively indicated that modern eHealth modalities are the most effective, with a 43% chance that mobile apps delivered the most effective interventions, followed by a 34% chance that interventions delivered via virtual reality were the most effective.

CONCLUSIONS

This systematic review with an NMA generated comparisons between eHealth modalities previously not compared to determine which delivered the most effective interventions for the reduction of pain interference in chronic pain patients. There are limitations with this review, in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated, a clear ranking of eHealth modalities for the reduction of pain interference will emerge.

Tertiary Care Clinical Experience with Intravenous Lidocaine Infusions for the Treatment of Chronic Pain

Objective

To evaluate the safety of and long-term pain relief due to intravenous lidocaine infusion for the treatment of chronic pain in a tertiary pain management clinic.

Design

Retrospective chart review.

Methods

Medical records were reviewed from 233 adult chronic pain patients who underwent one to three lidocaine infusions. The initial lidocaine challenge consisted of 1,000 mg/h administered intravenously for up to 30 minutes until infusion was complete, full pain resolution, the patient requested to stop, side effects (SEs) became intolerable, and/or if there were any safety concerns. Subsequent infusions were tailored to patient response. Data reviewed included pain diagnosis, lidocaine dose, SEs, and duration of pain relief documented at a follow-up visit.

Results

Patients primarily had neuropathic pain (80%), were 94% white, 58% were female, and there was an average pain duration of 7.9 years. SEs were usually mild and transient, including perioral tingling, dizziness, tinnitus, and nausea/vomiting, and they were uncommon after the initial infusion. Overall, 41% of patients showed long-lasting pain relief, with positive response to the initial infusion associated with receiving and benefitting from subsequent infusions. Benefit by pain diagnoses varied from 32% to 58%.

Conclusions

Our retrospective study in a heterogeneous population with chronic pain suggests that intravenous lidocaine is a safe treatment. Data also suggest long-term pain relief in a significant proportion of patients. Additional study is important in order to delineate patient selection, determine optimal dosing and treatment frequency, assess pain reduction and duration, and treatment cost-effectiveness.

Feasibility evaluation of a pain self-management app-based intervention among older people living with arthritic pain: study protocol

BACKGROUND

Optimal management of chronic arthritic pain experienced by older adults involves applying active self-management strategies every day. Cost-effective and innovative strategies to help build older people's pain self-management capability are required. This study protocol is designed to evaluate the feasibility, acceptability, and preliminary outcomes of a pain self-management app among older people living in the community with arthritic pain.

METHODS/DESIGN

This is a phase I feasibility study. A pre-post test study design will be used to trial a freely available pain self-management app named Rheumatoid Arthritis Information Support and Education ("RAISE") for 14 days. Thirty community-dwelling older people living with arthritic pain who use a smartphone will be recruited from (1) various community-based social clubs/organizations/groups or (2) via Facebook groups with potentially high number of older members. In addition, snowballing sampling approach will also be utilized.These participants will trial the RAISE app, which was selected following a systematic evaluation of all available chronic pain apps by the investigator team. A face-to-face or telephone-based meeting will be organized with all consenting participants in order to seek their informed consent, download and set up the intervention app on their mobile device, be provided with app training, and complete the pre-test data (Time 1 (T1)). Participants will be asked to use the RAISE app as desired for 14 days. Post-test data collection (Time 2 (T2)) will occur on day 15. Data collected includes participant's demographic and clinical information, pain scores, pain self-efficacy, and online technology self-efficacy. Participants will be invited to take part in a semi-structured telephone interview at T2 to explore their experiences of using the app.An evaluation of patterns of app use, recruitment, retention, attrition rates, and analysis of the missing data will inform the study and intervention feasibility. Preliminary outcomes are participant's pain intensity and interference, pain self-efficacy, and online technology self-efficacy.

DISCUSSION

This study will help us better understand the feasibility and acceptability of using this novel intervention among community-dwelling older people living with arthritic pain. The results will also help inform future pain app studies.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry: ACTRN12617000921381.

Patients' Needs and Requirements for eHealth Pain Management Interventions: Qualitative Study

BACKGROUND

A growing body of evidence supports the potential effectiveness of electronic health (eHealth) interventions in managing chronic pain. However, research on the needs and preferences of patients with chronic pain in relation to eHealth interventions is scarce. Eliciting user input in the development of eHealth interventions may be a crucial step toward developing meaningful interventions for patients for potentially improving treatment outcomes.

OBJECTIVE

This study aimed to explore the experiences of patients with chronic pain with regard to information and communication technology, understand how an eHealth intervention can support the everyday needs and challenges of patients with chronic pain, and identify possible facilitators and barriers for patients' use of an eHealth pain management intervention.

METHODS

Twenty patients living with chronic pain and five spouses participated in individual interviews. Semistructured interview guides were used to explore participants' needs, experiences, and challenges in daily life as well as their information and communication technology experiences and preferences for eHealth support interventions. Spouses were recruited and interviewed to gain additional insight into the patients' needs. The study used qualitative thematic analysis.

RESULTS

The participants were generally experienced technology users and reported using apps regularly. They were mainly in favor of using an eHealth self-management intervention for chronic pain and considered it a potentially acceptable way of gathering knowledge and support for pain management. The participants expressed the need for obtaining more information and knowledge, establishing a better balance in everyday life, and receiving support for improving communication and social participation. They provided suggestions for the eHealth intervention content and functionality to address these needs. Accessibility, personalization, and usability were emphasized as important elements for an eHealth support tool. The participants described an ideal eHealth intervention as one that could be used for support and distraction from pain, at any time or in any situation, regardless of varying pain intensity and concentration capacity.

CONCLUSIONS

This study provides insight into user preferences for eHealth interventions aiming to address self-management for chronic pain. Participants highlighted important factors to be considered when designing and developing eHealth interventions for self-management of chronic pain, illustrating the importance and benefit of including users in the development of eHealth interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104.

Use of Mobile Devices to Help Cancer Patients Meet Their Information Needs in Non-Inpatient Settings: Systematic Review

BACKGROUND

The shift from inpatient to outpatient cancer care means that patients are now required to manage their condition at home, away from regular supervision by clinicians. Subsequently, research has consistently reported that many patients with cancer have unmet information needs during their illness. Mobile devices, such as mobile phones and tablet computers, provide an opportunity to deliver information to patients remotely. To date, no systematic reviews have evaluated how mobile devices have been used specifically to help patients meet to their information needs.

OBJECTIVE

A systematic review was conducted to identify studies that describe the use of mobile interventions to enable patients with cancer meet their cancer-related information needs in non-inpatient settings, and to describe the effects and feasibility of these interventions.

METHODS

MEDLINE, Embase, and PsycINFO databases were searched up until January 2017. Search terms related to "mobile devices," "information needs," and "cancer" were used. There were no restrictions on study type in order to be as inclusive as possible. Study participants were patients with cancer undergoing treatment. Interventions had to be delivered by a mobile or handheld device, attempt to meet patients' cancer-related information needs, and be for use in non-inpatient settings. Critical Appraisal Skills Programme checklists were used to assess the methodological quality of included studies. A narrative synthesis was performed and findings were organized by common themes found across studies.

RESULTS

The initial search yielded 1020 results. We included 23 articles describing 20 studies. Interventions aimed to improve the monitoring and management of treatment-related symptoms (17/20, 85%), directly increase patients' knowledge related to their condition (2/20, 10%), and improve communication of symptoms to clinicians in consultations (1/20, 5%). Studies focused on adult (17/20; age range 24-87 years) and adolescent (3/20; age range 8-18 years) patients. Sample sizes ranged from 4-125, with 13 studies having 25 participants or fewer. Most studies were conducted in the United Kingdom (12/20, 52%) or United States (7/20, 30%). Of the 23 articles included, 12 were of medium quality, 9 of poor quality, and 2 of good quality. Overall, interventions were reported to be acceptable and perceived as useful and easy to use. Few technical problems were encountered. Adherence was generally consistent and high (periods ranged from 5 days to 6 months). However, there was considerable variation in use of intervention components within and between studies. Reported benefits of the interventions included improved symptom management, patient empowerment, and improved clinician-patient communication, although mixed findings were reported for patients' health-related quality of life and anxiety.

CONCLUSIONS

The current review highlighted that mobile interventions for patients with cancer are only meeting treatment or symptom-related information needs. There were no interventions designed to meet patients' full range of cancer-related information needs, from information on psychological support to how to manage finances during cancer, and the long-term effects of treatment. More comprehensive interventions are required for patients to meet their information needs when managing their condition in non-inpatient settings. Controlled evaluations are needed to further determine the effectiveness of these types of intervention.

Benefits of Mobile Apps in Pain Management: Systematic Review

Background

Pain is a common condition with a significant physical, psychosocial, and economic impact. Due to enormous progress in mobile device technology as well as the increase in smartphone ownership in the general population, mobile apps can be used to monitor patients with pain and support them in pain management.

Objective

The aim of this review was to assess the efficacy of smartphone or computer tablet apps in the management of patients with pain.

Methods

In December 2017, a literature search was performed in the following databases: MEDLINE, EMBASE, CINAHL, Cochrane, and PsycINFO. In addition, a bibliography search was conducted. We included studies with at least 20 participants per arm that evaluated the effects of apps on smartphones or computer tablets on improvement in pain.

Results

A total of 15 studies with 1962 patients met the inclusion criteria. Of these, 4 studies examined the effect of mobile apps on pain management in an in-clinic setting and 11 in an out-clinic setting. The majority of the original studies reported beneficial effects of the use of a pain app. Severity of pain decreased in most studies where patients were using an app compared with patients not using an app. Other outcomes, such as worst pain or quality of life showed improvements in patients using an app. Due to heterogeneity between the original studies—patient characteristics, app content, and study setting—a synthesis of the results by statistical methods was not performed.

Conclusions

Apps for pain management may be beneficial for patients, particularly in an out-clinic setting. Studies have shown that pain apps are workable and well liked by patients and health care professionals. There is no doubt that in the near future, mobile technologies will develop further. Medicine could profit from this development as indicated by our results, but there is a need for more scientific inputs. It is desirable to know which elements of apps or additional devices and tools may improve usability and help patients in pain management.

Determining Pain Catastrophizing From Daily Pain App Assessment Data: Role of Computer-Based Classification

This study compared persons with chronic pain who consistently reported that their pain was worsening with those who reported that their pain was improving or remaining the same per daily assessment data from a smartphone pain app. All participants completed baseline measures and were asked to record their progress every day by answering whether their overall condition had improved, remained the same, or gotten worse (perceived change) on a visual analogue scale. One hundred forty-four individuals with chronic pain who successfully entered daily assessments were included. Those persons who were classified as worse showed significantly higher pain intensity scores, greater activity interference, higher disability and mood disturbance scores, and higher scores on the Pain Catastrophizing Scale both at baseline and after 3 months (P < .001). Repeated measures analyses and multilevel modeling of perceived change data over different time intervals of 20 assessments over 40 days, 10 assessments over 20 days, and 5 assessments over 10 days were examined. These analyses demonstrated that group classification of better, same, and worse could be reliably determined, even with as few as 5 assessments. These results support the use of innovative mobile health technology to identify individuals who are prone to catastrophize about their pain. Perspective: This study demonstrated that daily assessment of overall perceived change with a smartphone pain app was positively correlated with the Pain Catastrophizing Scale and capturing short-term daily assessment trends data using computer-based classification methods might be a future way to help to identify individuals who tend to catastrophize about their pain.

An mHealth Intervention for Persons with Diabetes Type 2 Based on Acceptance and Commitment Therapy Principles: Examining Treatment Fidelity

Background

Web-based interventions are becoming an alternative of treatment aimed to support behavioral changes and several advantages over traditional treatments are reported. New ways of delivering an intervention may result in new challenges regarding monitoring of treatment fidelity (TF) which is essential to ensure internal and external validity. Despite the importance of the theme, only a few studies in this field are reported.

Objective

To examine TF of a mobile phone delivered intervention based on Acceptance and Commitment Therapy (ACT) with electronic diaries and written situational feedback for persons with diabetes mellitus type 2, the recommendations from the Behavior Change Consortium (BCC) established by The National Institutes of Health (NHI) were applied. To analyze fidelity, they recommend 5 areas to be investigated (1) design of the study, (2) provider training, (3) delivery of treatment, (4) receipt of treatment, and (5) enactment of treatment. In the current study, these areas were examined based on the analysis of therapists’ adherence to the treatment protocol and participants’ and therapists’ experience with the intervention.

Methods

To investigate the therapists’ adherence to the treatment protocol, a total of 251 written feedback text messages were divided into text segments. Qualitative thematic analyses were then performed to examine how ACT and other therapeutic processes were used in the feedback by the therapists. For the therapists’ and participants’ experience analysis, participants answered a self-reported questionnaire and participated in 2 interviews. The therapists continuously reported their experiences to the researcher responsible for the project.

Results

The results show high adherence to the TF strategies 20/21 (95%) applicable items of the fidelity checklist recommended by NHI BCC were identified in the present study. Measured provider skill acquisition post-training was the only item absent in the fidelity checklist. The results also show high therapists’ adherence to the treatment protocol. All ACT processes (values, committed action, acceptance, contact with the present moment, self as context and cognitive defusion) were found in the coded text segments of the feedback in addition to communication and motivation strategies. For 336/730 (46%) of total possible text segments coded independently by 2 researchers, the interrater reliability measured by Cohen’s kappa was .85. The evaluation of participants’ and therapists’ experience with the intervention was generally positive.

Conclusions

Based on the analyses of therapists’ adherence to the treatment protocol grounded by ACT-principles and participants’ and therapists’ experience with the intervention, the 5 areas of TF recommended by NHI BCC were analyzed indicating a high level of TF. These results ensure an appropriate level of internal and external validity of the study and reliable intervention results and facilitate a precise replication of this intervention concept. Web-based psychological interventions to support people with chronic conditions are becoming increasingly more common. This study supports the results from a previous study which indicated that ACT could be reliably delivered in a written web-based format.

Trial Registration

ClinicalTrials.gov NCT01297049; https://clinicaltrials.gov/ct2/show/NCT01297049 (Archived by WebCite at http://www.webcitation.org/70WC4Cm4T)

The effectiveness of various computer-based interventions for patients with chronic pain or functional somatic syndromes: A systematic review and meta-analysis

Computer-based interventions target improvement of physical and emotional functioning in patients with chronic pain and functional somatic syndromes. However, it is unclear to what extent which interventions work and for whom. This systematic review and meta-analysis (registered at PROSPERO, 2016: CRD42016050839) assesses efficacy relative to passive and active control conditions, and explores patient and intervention factors. Controlled studies were identified from MEDLINE, EMBASE, PsychInfo, Web of Science, and Cochrane Library. Pooled standardized mean differences by comparison type, and somatic symptom, health-related quality of life, functional interference, catastrophizing, and depression outcomes were calculated at post-treatment and at 6 or more months follow-up. Risk of bias was assessed. Sub-group analyses were performed by patient and intervention characteristics when heterogeneous outcomes were observed. Maximally, 30 out of 46 eligible studies and 3,387 participants were included per meta-analysis. Mostly, internet-based cognitive behavioral therapies were identified. Significantly higher patient reported outcomes were found in comparisons with passive control groups (standardized mean differences ranged between -.41 and -.18), but not in comparisons with active control groups (SMD = -.26 - -.14). For some outcomes, significant heterogeneity related to patient and intervention characteristics. To conclude, there is a minority of good quality evidence for small positive average effects of computer-based (cognitive) behavior change interventions, similar to traditional modes. These effects may be sustainable. Indications were found as of which interventions work better or more consistently across outcomes for which patients. Future process analyses are recommended in the aim of better understanding individual chances of clinically relevant outcomes.

The Efficacy and Acceptability of Third-Wave Behavioral and Cognitive eHealth Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

eHealth is an innovative method of delivering therapeutic content with the potential to improve access to third-wave behaviural and cognitive therapies. This systematic review and meta-analysis aimed to determine the efficacy and acceptability of third-wave eHealth treatments in improving mental health outcomes. A comprehensive search of electronic bibliographic databases including PubMed, PsycINFO, Web of Science, and CENTRAL was conducted to identify randomized controlled trials of third-wave treatments in which eHealth was the main component. Twenty-one studies were included in the review. Meta-analyses revealed that third-wave eHealth significantly outperformed inactive control conditions in improving anxiety, depression, and quality-of-life outcomes and active control conditions in alleviating anxiety and depression with small to medium effect sizes. No statistically significant differences were found relative to comparison interventions. Findings from a narrative synthesis of participant evaluation outcomes and meta-analysis of participant attrition rates provided preliminary support for the acceptability of third-wave eHealth. Third-wave eHealth treatments are efficacious in improving mental health outcomes including anxiety, depression, and quality of life, but not more so than comparison interventions. Preliminary evidence from indices of participant evaluation and attrition rates supports the acceptability of these treatments.

A First Step Towards Behavioral Coaching for Managing Stress: A Case Study on Optimal Policy Estimation with Multi-stage Threshold Q-learning

Psychological stress is a major contributor to the adoption of unhealthy behaviors, which in turn accounts for 41% of global cardiovascular disease burden. While the proliferation of mobile health apps has offered promise to stress management, these apps do not provide micro-level feedback with regard to how to adjust one's behaviors to achieve a desired health outcome. In this paper, we formulate the task of multi-stage stress management as a sequential decision-making problem and explore the application of reinforcement learning to provide micro-level feedback for stress reduction. Specifically, we incorporate a multi-stage threshold selection into Q-learning to derive an interpretable form of a recommendation policy for behavioral coaching. We apply this method on an observational dataset that contains Fitbit ActiGraph measurements and self-reported stress levels. The estimated policy is then used to understand how exercise patterns may affect users' psychological stress levels and to perform coaching more effectively.