Older Adult Use and Outcomes in a Digital Musculoskeletal (MSK) Program, by Generation

The potential of a multimodal digital care program in addressing healthcare inequities in musculoskeletal pain management

Digital interventions have emerged as a solution for time and geographical barriers, however, their potential to target other social determinants of health is largely unexplored. In this post-hoc analysis, we report the impact of social deprivation on engagement and clinical outcomes after a completely remote multimodal musculoskeletal (MSK) digital care program managed by a culturally-sensitive clinical team. Patients were stratified in five categories according to their social deprivation index, and cross-referenced with their race/ethnicity, rurality and distance to healthcare facilities. From a total of 12,062 patients from all U.S. states, 8569 completed the program. Higher social deprivation was associated with greater baseline disease burden. We observed that all categories reported pain improvements (ranging from -2.0 95%CI -2.1, -1.9 to -2.1 95%CI -2.3, -1.9, p < 0.001) without intergroup differences in mean changes or responder rates (from 59.9% (420/701) to 66.6% (780/1172), p = 0.067), alongside reduction in analgesic consumption. We observed significant improvements in mental health and productivity across all categories, with productivity and non-work-related functional recovery being greater within the most deprived group. Engagement was high but varied slightly across categories. Together these findings highlight the importance of a patient-centered digital care program as a tool to address health inequities in musculoskeletal pain management. The idea of investigating social deprivation within a digital program provides a foundation for future work in this field to identify areas of improvement.

Managing Musculoskeletal Pain in Older Adults Through a Digital Care Solution: Secondary Analysis of a Prospective Clinical Study

BACKGROUND

Aging is closely associated with an increased prevalence of musculoskeletal conditions. Digital musculoskeletal care interventions emerged to deliver timely and proper rehabilitation; however, older adults frequently face specific barriers and concerns with digital care programs (DCPs).

OBJECTIVE

This study aims to investigate whether known barriers and concerns of older adults impacted their participation in or engagement with a DCP or the observed clinical outcomes in comparison with younger individuals.

METHODS

We conducted a secondary analysis of a single-arm investigation assessing the recovery of patients with musculoskeletal conditions following a DCP for up to 12 weeks. Patients were categorized according to age: ≤44 years old (young adults), 45-64 years old (middle-aged adults), and ≥65 years old (older adults). DCP access and engagement were evaluated by assessing starting proportions, completion rates, ability to perform exercises autonomously, assistance requests, communication with their physical therapist, and program satisfaction. Clinical outcomes included change between baseline and program end for pain (including response rate to a minimal clinically important difference of 30%), analgesic usage, mental health, work productivity, and non-work-related activity impairment.

RESULTS

Of 16,229 patients, 12,082 started the program: 38.3% (n=4629) were young adults, 55.7% (n=6726) were middle-aged adults, and 6% (n=727) were older adults. Older patients were more likely to start the intervention and to complete the program compared to young adults (odds ratio [OR] 1.72, 95% CI 1.45-2.06; P<.001 and OR 2.40, 95% CI 1.97-2.92; P<.001, respectively) and middle-aged adults (OR 1.22, 95% CI 1.03-1.45; P=.03 and OR 1.38, 95% CI 1.14-1.68; P=.001, respectively). Whereas older patients requested more technical assistance and exhibited a slower learning curve in exercise performance, their engagement was higher, as reflected by higher adherence to both exercise and education pieces. Older patients interacted more with the physical therapist (mean 12.6, SD 18.4 vs mean 10.7, SD 14.7 of young adults) and showed higher satisfaction scores (mean 8.7, SD 1.9). Significant improvements were observed in all clinical outcomes and were similar between groups, including pain response rates (young adults: 949/1516, 62.6%; middle-aged adults: 1848/2834, 65.2%; and older adults: 241/387, 62.3%; P=.17).

CONCLUSIONS

Older adults showed high adherence, engagement, and satisfaction with the DCP, which were greater than in their younger counterparts, together with significant clinical improvements in all studied outcomes. This suggests DCPs can successfully address and overcome some of the barriers surrounding the participation and adequacy of digital models in the older adult population.

Smartphone app-delivered gut-directed hypnotherapy improves symptoms of self-reported irritable bowel syndrome: A retrospective evaluation

BACKGROUND

Gut-directed hypnotherapy (GDH) has high rates of durable efficacy for treating irritable bowel syndrome (IBS) but its widespread use is limited due to high costs and poor access. A smartphone app delivering GDH was developed to fill gaps in accessibility but has not been assessed in IBS patients. The current retrospective evaluation aims to assess the efficacy of app-delivered GDH in managing IBS symptoms and to investigate associating factors that predict response.

METHODS

Irritable bowel syndrome patients who downloaded the app between June 2019 and April 2020 were retrospectively evaluated. The first seven sessions were free. Daily GDH, psycho-education, and breathing exercises were included. Overall and individual gastrointestinal symptoms were assessed at baseline and completion using a 100-mm visual analogue scale. Clinical data were extracted.

KEY RESULTS

2843 patients with self-reported IBS commenced the free sessions, 1428 (50%) purchased the app and 253 (9%) completed all 42 sessions. Outcome data were available for 190 users who completed all 42 sessions. 64% of patients who completed the GDH and provided outcome data responded (defined as >30% reduction in abdominal pain). Abdominal pain reduced from 60mm (50-73mm) at baseline to 26mm (13-50mm) on study completion (p<0.001 Wilcoxon). Similar results were seen for overall and individual symptoms. On multivariable analysis, symptom response was positively associated with being ≥ 40 years (estimated OR 0.398, p=0.025) and negatively associated with trying probiotics (0.323, p=0.042).

CONCLUSIONS & INFERENCES

Adherence to app-delivered gut-directed hypnotherapy was low but users who completed the program saw notable improvements in their IBS symptoms. Patients ≥40 years, with symptoms for ≥5 years, may respond better. A controlled trial comparing face-to-face to app-delivered GDH is indicated.

Personalizing digital pain management with adapted machine learning approach

Introduction

Digital therapeutics (DT) emerged and has been expanding rapidly for pain management. However, the efficacy of such approaches demonstrates substantial heterogeneity. Machine learning (ML) approaches provide a great opportunity for personalizing the efficacy of DT. However, the ML model accuracy is mainly associated with reduced clinical interpretability. Moreover, classical ML models are not adapted for the longitudinal nature of the DT follow-up data, which may also include nonlinear fluctuations.

Objectives

This study presents an analytical framework for personalized pain management using piecewise mixed-effects model trees, considering the data dependencies, nonlinear trajectories, and boosting model interpretability.

Methods

We demonstrated the implementation of the model with posture biofeedback training data of 3610 users collected during 8 weeks. The users reported their pain levels and posture quality. We developed personalized models for nonlinear time-related fluctuations of pain levels, posture quality, and weekly training duration using age, gender, and body mass index as potential moderating factors.

Results

Pain levels and posture quality demonstrated strong improvement during the first 3 weeks of the training, followed by a sustained pattern. The age of the users moderated the time fluctuations in pain levels, whereas age and gender interactively moderated the trajectories in the posture quality. Train duration increased during the first 3 weeks only for older users, whereas all the users decreased the training duration during the next 5 weeks.

Conclusions

This analytical framework offers an opportunity for investigating the personalized efficacy of digital therapeutics for pain management, taking into account users' characteristics and boosting interpretability and can benefit from including more users' characteristics.

Clinical outcomes one year after a digital musculoskeletal (MSK) program: an observational, longitudinal study with nonparticipant comparison group

Background

The evidence base for the impact of digital health on musculoskeletal (MSK) outcomes is growing, but it is unclear how much digital MSK programs address pain and function in the intermediate and long term.

Methods

This observational study of digital MSK program participants versus nonparticipants (n = 2570) examined pain, function, depression, and anxiety at 3, 6, and 12 months, and health care use at 12 months. The intervention group engaged in a digital MSK program that included exercise, education, and coaching for at least 3 months. The nonparticipant group registered, but never started the program. We collected data in app or by emailed survey at 3, 6, and 12 months after registering for the program. We conducted descriptive analyses and unadjusted and adjusted regression modeling.

Results

The odds ratio of achieving a minimally clinically important difference (MCID) in pain improvement for the intervention versus the nonparticipant group was 1.97 (95% CI: 1.28, 3.02; p = .002) at 3 months, 1.44 (95% CI: 0.91, 2.25; p = .11) at 6 months, and 2.06 (95% CI: 1.38, 3.08; p = .004) at 12 months in adjusted models. The odds ratio of achieving a MCID in functional improvement for the intervention versus the nonparticipant group was 1.56 (95% CI: 1.03, 2.38; p = .01) at 3 months, 1.55 (95% CI: 1.02, 2.37; p = .04) at 6 months, and 1.35 (95% CI: 0.89, 2.06, p = 0.16) at 12 months in adjusted models. For those with moderate to severe depression or anxiety at baseline, we observed statistically significant lower odds of moderate to severe depression or anxiety at 3 months, 6 months, and 12 months for the intervention versus the nonparticipant group in adjusted models (p < .05). At 12 months, the percentage with invasive, imaging, and conservative services was higher for the nonparticipant versus intervention group by 5.7, 8.1, and 16.7 percentage points, respectively (p < 0.05).

Conclusions

A digital MSK program may offer participants sustained improvement in pain, depression, and anxiety with concomitant decreases in health care use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05188-x.