June 2022, Volume 72, Issue 6

Systematic Review

Digital technologies in management of chronic pain — a systematic review

Afshan Hussain  ( Department of Physical Therapy, University of Lahore, Lahore, Pakistan. )
Husna Haroon  ( University Institute of Physical Therapy, University of Lahore, Lahore, Pakistan. )
Ashfaq Ahmed  ( University of Lahore, University Institute of Physical Therapy (UIPT), Lahore,Pakistan. )
Syed Amir Gilani  ( Department of Radiology, Faculty of Allied Health Sciences, The University of Lahore )

Abstract

Objective: To determine the effectiveness of digital health technologies in the management of chronic pain.

 

Methods: The systematic review comprised search for randomised controlled trials and controlled clinical trials involving patients with chronic pain published between 2010 and 2020. The search was conducted on PubMed, Google Scholar, MEDLINE, National Centre for Biotechnology Information, and National Library of Medicine databases. Risk bias tool was used to evaluate the biasness in the studies and Pedro scale was used to assess the quality of the included articles.

 

Results: Of the 33 articles fully assessed, 14(42.42%) were analysed. All the studies analysed were randomised controlled trials and scored 6-10 on the Pedro scale which showed high quality of methodology. The studies typically reported statistically significant benefits of digital health technologies in the management of chronic pain. One of the main benefits was enhanced pain coping skills of the patients. Additionally, majority of the studies included increased adherence to exercise as an essential advantage.

 

Conclusion: All the studies analysed reported favourable conclusions regarding the use of digital intervention for chronic pain management.

 

Keywords: Chronic pain, Digital intervention, Health technologies, Pain management, Randomised controlled trial.

 

DOI:  https://doi.org/10.47391/JPMA.3885

 

Introduction

 

Increasingly, the internet has been used to provide healthcare interventions as a time-efficient and convenient method, particularly in cases with chronic pain. The internet is believed to be used by about 34% of the world's population; roughly 2.4 billion people.

Interestingly, the age group with the fastest increasing internet usage is the older adults. The internet is, therefore, a viable mode of communication to allow initiatives to reach a large number of people, particularly older adults living in remote areas.1

Individuals who are likely to use the internet on a daily basis via cell phones, tablets or computers are gaining acceptance towards this mode of interaction. A creative online support resource can also provide an interactive means of following the rehabilitation of patients in a way that is readily accessible.2

While telehealth provides modern conveniences and possibly expanded access to care, especially for patients with limited mobility, for the continuity of treatment, the patient remains heavily reliant on a therapist. For acute and chronic pain, remote therapeutics provide independent, home-based and on-demand access to care.

Digital multi-session therapies have been shown to be successful for chronic pain. Despite these accomplishments, any one procedure will not fulfil everyone's needs; even web-based pain treatments available have engagement rates of <60%, indicating the need to give a wide variety of affordable services for chronic pain management.3 In the acute-care environment, efficient and secure pain control is an important task. Pain affects about half of hospitalised patients, with one-quarter of those experiencing "unbearable" pain. Pain care, including opioids, is typically pharmacological management, which can lead to contradictions and suboptimal results. Data from the United States Centres for Disease Control and Prevention (CDC) indicates that one year later, even a single-day use of opioid treatment anticipates a 6% chance of dependence. Thus, in hospitalised patients, there is an urgent prerequisite for protected, well-founded, drug-related alternatives for pain management.4

Service delivery interventions for telemedicine and eHealth are being attempted and found to be innovative in many cases. Technology for communication is comparatively inexpensive to use. Connection with patients is essentially possible if the staff and facilities are available.5

The current systematic review was planned to determine the effectiveness of digital health technologies in the management of chronic pain.

 

Materials and Methods

 

The systematic review comprised search for randomised controlled trials (RCTs) and controlled clinical trials involving patients with chronic pain published between 2010 and 2020. The search was conducted on PubMed, Google Scholar, MEDLINE, National Centre for Biotechnology Information (NCBI), and National Library of Medicine (NLM) databases.

Studies were included if the study participants had access to any form of digital source, had participants of either gender regardless of age, had been peer-reviewed, published in professional and scientific journals, contained any standardised assessment tool of the intervention's outcome, were RCTs or controlled clinical trials, and were published in English language between 2010 and 2020.

Studies were excluded if the patients in the study suffered from any other traumatic injury that required regular hospital visits or hospital admissions, any form of editorials, commentaries, case series, textbook articles, studies written in languages other than English, presence of health condition that affected the rehabilitation programme, if the participants did not have access to any form of digital source, and studies that did not have any protocol to ensure or validate if the participants attended the treatment.

The key words used for the search were: 'telehealth', 'telemedicine', 'web-based exercise', 'internet delivered exercise', 'chronic pain', 'osteoarthritis', 'SMS service', 'low back pain', 'VR', 'pain coping skills', 'persistent pain', 'musculoskeletal conditions', 'digital activity', and 'digital health'. There was also a manual check of references from the retrieved journals. Boolean terms included digital intervention AND chronic pain management OR pain coping skills.

Comparison groups were considered.

Primary outcome of interest was overall adherence to exercise, adherence to number of exercise sessions, pain intensity, level of activity, and disability.

Secondary outcomes included movement activity, cognitive predictors of behavioural change and health-related variables, and satisfaction with digital intervention experiences.

Risk bias tool was used to evaluate the biasness in the studies, and Pedro scale6 was used to assess the quality of the included studies.

 

Results

 

Of the 33 articles fully assessed, 14(42.42%) were analysed in detail (Figure). All the studies analysed scored 6-10 on the Pedro scale which showed high quality of methodology (Table-1).

 

 

 

 

All the studies analysed were RCTs, reporting statistically significant benefits of digital health technologies in the management of chronic pain. One of the main benefits was enhanced pain coping skills of the patients. Additionally, majority of the studies included increased adherence to exercise as another essential advantage (Table-2).

 

 

Risk bias of each study was also evaluated (Table-3).

 

 

Discussion

 

The systematic review analysed 14 studies that met the inclusion criteria.2,4,6-17 Despite a rapid uptake of technology in the health community, there has been little high-quality research to determine the efficacy of such technology in the field of physiotherapy. The studies included in the current review provide positive evidence in that digital technologies can indeed improve patients' ability to manage pain and also conditions that cause chronic pain. All the 14 studies included used different types of digital interventions with different strategies. It is very important as it can be added to the generalisation capacity of the current review. Even though there is very little difference of opinion in the studies, all of them support the view that digital interventions do help patients manage their pain better.

A study by Lambert et al2 2017 discussed how efficient it was to provide HEPs (home exercise programmes) using an app in conjunction with text messages and phone calls in order to address a practical question about the efficacy of a "set" of interventions delivered via technology versus paper handouts.

Kim et al7 in 2017 compared the effects of traditionally prescribed home workouts with that of an online intervention which combined physiotherapist-prescribed home workout, Skype sessions with a physiotherapist and an immersive PCST (Pain-coping skills training) software.

Another study6 by Bennell et al. stated that traditional approaches used by physical therapists to administer exercise to patients with musculoskeletal disorders when compared with a publicly accessible web-based exercise programming framework resulted in better symptom control.

Harmelink et al.8 evaluated how successful an activity coaching system was when combined with a home-based fitness routine.

Nelligan et al.10 compared the effects of a digitally distributed intervention combining "My Knee Workout," a website with knee osteoarthritis (OA) and exercise instruction advice with that of only an education guidance.

Rutledge et al.17 compared the effects of telephone delivered CBT (Cognitive behavioural therapy) for pain management with that of supportive care condition that basically involves education using standard textbooks, active listening and maintaining current medications and treatment practice.

The efficacy of a new programme, the pain course in reducing disability and anxiety, was explored by B.F. Dear et al.11

Eaton et al.12 evaluated the effects of tele-mentoring and the impact it had on pain management on patient outcomes.

Another study by B.F. Dear et al.13 explored the efficacy of an internet pain course programme in combination with video conferences with the clinician compared with no clinician support at all.

Rini et al.14 evaluated an internet-delivered automated PainCOACH (An Internet-based interactive PCST programme) PCST intervention compared to an assessment-only group.

Palermo et al.15 demonstrated the effectiveness of an internet-based CBT programme for paediatric pain and disability. The intervention was compared to a waitlist group.

Connelly et al.16 sought to determine the effect of an online self-management programme which included multimedia-based modules on pain and health-related quality of life in adolescents with juvenile idiopathic arthritis.

Spiegel B et al.4 evaluated the effectiveness of therapeutic Virtual Reality (VR) compared with yoga and meditation sessions, poetry readings and discussions on health and wellness topics.

 

Conclusion

 

All the 14 studies supported the use of digital technologies in pain management as it increased compliance and confidence of using the given intervention while improving participants' sleep quality. The studies suggested that there is a potential for sustained benefits.

 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None.

 

References

 

1.       Dobson F, Hinman RS, French S, Rini C, Keefe F, Nelligan R, et al. Internet-mediated physiotherapy and pain coping skills training for people with persistent knee pain (IMPACT - Knee pain): A randomised controlled trial protocol. BMC Musculoskelet Disord. 2014; 15:1-13.

2.       Firs TD, Tara N, Firs ETD, Td N, Lambert S, Surname TD, et al. An app with remote support achieves better adherence to home exercise programs than paper handouts in people with musculoskeletal conditions?: a randomised trial. J Physiother. 2017; 63:161-7.

3.       Darnall BD, Krishnamurthy P, Tsuei J, Minor JD. Self-administered skills-based virtual reality intervention for chronic pain: randomized controlled pilot study. JMIR Form Res. 2020;4: e17293.

4.       Spiegel B, Fuller G, Lopez M, Dupuy T, Noah B, Howard A, et al. Virtual reality for management of pain in hospitalized patients: A randomized comparative effectiveness trial. PLoS One. 2019; 14:1-15.

5.       Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, Lynch ME, et al. Managing patients with chronic pain during the COVID-19 outbreak: considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain. 2020; 161:889-93.

6.       Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003; 83:713-21.

7.       Bennell KL, Marshall CJ, Dobson F, Kasza J, Lonsdale C, Hinman RS. Does a Web-Based Exercise Programming System Improve Home Exercise Adherence for People with Musculoskeletal Conditions?: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2019; 98:850-8.

8.       Bennell KL, Nelligan R, Dobson F, Rini C, Keefe F, Kasza J, et al. Effectiveness of an internet-delivered exercise and pain-coping skills training intervention for persons with chronic knee pain: A randomized trial. Ann Intern Med. 2017; 166:453-62.

9.       Harmelink KEM, Zeegers AVCM, Tönis TM, Hullegie W, Nijhuis-Van Der Sanden MWG, Staal JB. The effectiveness of the use of a digital activity coaching system in addition to a two-week home-based exercise program in patients after total knee arthroplasty: Study protocol for a randomized controlled trial. BMC Musculoskelet Disord. 2017; 18:1-10.

10.    Chen HC, Chuang TY, Lin PC, Lin YK, Chuang YH. Effects of Messages Delivered by Mobile Phone on Increasing Compliance With Shoulder Exercises Among Patients With a Frozen Shoulder. J Nurs Scholarsh. 2017; 49:429-37.

11.    Nelligan RK, Hinman RS, Kasza J, Bennell KL. Effectiveness of internet-delivered education and home exercise supported by behaviour change SMS on pain and function for people with knee osteoarthritis: A randomised controlled trial protocol. BMC Musculoskelet Disord. 2019; 20:1-11.

12.    Dear BF, Titov N, Perry KN, Johnston L, Wootton BM, Terides MD, et al. The Pain Course: A randomised controlled trial of a clinician-guided Internet-delivered cognitive behaviour therapy program for managing chronic pain and emotional well-being. Pain. 2013; 154:942-50.

13.    Eaton LH, Godfrey DS, Langford DJ, Rue T, Tauben DJ, Doorenbos AZ. Telementoring for improving primary care provider knowledge and competence in managing chronic pain: A randomised controlled trial. J Telemed Telecare. 2020; 26:21-7.

14.    Dear BF, Gandy M, Karin E, Fogliati R, Fogliati VJ, Staples LG, et al. The Pain Course: 12- and 24-Month Outcomes From a Randomized Controlled Trial of an Internet-Delivered Pain Management Program Provided With Different Levels of Clinician Support. J Pain. 2018; 19:1491-503.

15.    Rini C, Porter LS, Somers TJ, McKee DC, DeVellis RF, Smith M, et al. Automated Internet-based pain coping skills training to manage osteoarthritis pain: A randomized controlled trial. Pain. 2015; 156:837-48.

16.    Palermo TM, Law EF, Fales J, Bromberg MH, Jessen-Fiddick T, Tai G. Internet-delivered cognitive-behavioral treatment for adolescents with chronic pain and their parents: A randomized controlled multicenter trial. Pain. 2016; 157:174-85.

17.    Connelly M, Schanberg LE, Ardoin S, Blakley M, Carrasco R, Chira P, et al. Multisite randomized clinical trial evaluating an online selfmanagement program for adolescents with juvenile idiopathic arthritis. J Pediatr Psychol. 2019; 44:363-74.

18.     Rutledge T, Atkinson JH, Chircop-Rollick T, D'Andrea J, Garfin S, Patel S, et al. Randomized Controlled Trial of Telephone-delivered Cognitive Behavioral Therapy Versus Supportive Care for Chronic Back Pain. Clin J Pain. 2018; 34:322-7.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: