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Health Apps Help with Medication Management, but How Can Pain Specialists Use Them More Effectively?

March 19, 2021
From behavioral tracking to improved access to healthcare, emerging health apps may change how chronic pain is managed at home – and in the pain clinic.

with Tiziano Marovino, DPT

The adoption of digital solutions and health apps to deliver medical care has expanded during the COVID-19 pandemic, with new technology providing viable options to manage chronic illness – including chronic pain.

Despite the prevalence and high cost, “there are barriers to improving the management and outcomes of chronic pain, including obtaining longitudinal data, assessing response to interventions, and addressing challenges to communication between patients and health care providers,” wrote Anuj Bhatia, MD, of the University of Toronto, Canada, and colleagues.1

Although several pain management apps have been developed to help bridge some of these gaps, they often “evaluate the biopsychosocial components of pain experiences inadequately and lack clinical involvement,” wrote Bhatia’s team.1 One of these health apps, Manage My Pain, was launched in 2011 to help patients track pain and medication response. In 2019, the developers issued a revamped version that reports trends for clinicians and facilitates doctor-patient dialogue. While previous studies analyzed the app’s patterns of use, its clinical impact had not been well studied.

Real-World Implementation of a Pain Management App

In a prospective, open-label study published in JMIR mHealth and uHealth, Bhatia et al shared results on patient engagement with the Manage My Pain app for the management of chronic pain. They recruited 246 adults with chronic pain at one rural and two urban pain clinics. Subjects completed baseline questionnaires on anxiety, depression, pain catastrophizing, satisfaction, and daily opioid use for up to 4.5 months after a baseline visit as short-term follow-up, and again between 4.5 and 7 months after the baseline visit as long-term follow-up. Patients who used the app for at least 30 days were compared to controls who did not use the app; the average duration of app use was 164 days.

Notably, app users reported significant decreases in anxiety and pain catastrophizing compared to non-users.

The app prompts patients to record daily reflections, and goals, and allows them to input activities they accomplished and to rate their pain during activities. After providing this information, they can view charts and graphs that show behavior patterns and trends in pain, pain response, and pain triggers. In addition, reports summarize and store the information for review by patients and their doctors during clinical visits. The app also includes a monitoring portal for clinicians to assess patients remotely, assign them questionnaires, and highlight behavior patterns.

A total of 181 participants agreed to use the app, and of these, 111 (63.4%) used it for at least 1 month, 45.1% continued using the app beyond 1 month, and 28.0% used it for 4.5 to 7 months. The remaining participants who declined to use the app or those who registered with the app but had no records beyond 30 days served as controls.

At short-term follow-up, participants who used the Manage My Pain app showed a significant reduction in anxiety compared to controls, with an average of 2.10 points reduction on the Generalized Anxiety Disorder 7-item questionnaire.  At long-term follow-up, app users showed significantly reduced levels of pain catastrophizing compared to controls, with an average of 5.23 points reduction on the Pain Catastrophizing Scale score.

The real-world use study findings were limited by several factors, as noted by the research team, including: the lack of randomization and reliance on self-reports, as well as the high drop-off in-app use from baseline to short-term follow-up among controls, which may have contributed bias to the results.

“The rates of initial engagement with the app reported in our study—initially 73.6% (181/246), with a gradual decrease to 28.0% (69/246) at the long-term follow-up—are consistent with those reported in literature by our group and others, and appear to be better than the rates for other apps,” the researchers wrote. “Digital pain management applications and other health-related clinical applications deserve significant attention in the years ahead, given the push toward mobile health tools and telemedicine,” they concluded.

There are benefits to health app use in pain management, including potential improvement of patient-provider communication and the empowerment of patients to manage their pain experience. (iStock)

Health App Technology Extends to Pain Management

PPM talked to Tiziano Marovino, DPT, FAAPM, the SVP of Health Strategy and Innovation for the Biogenesis Group, to get his take. In general, he noted that Bhatia’s study is important because technology now permeates all aspects of our lives, and pain management is no exception.

“Apps are a way in which we can interact with a technology platform in a user-friendly manner, and if a pain app becomes available that can help people experiencing chronic intractable pain to suffer less, then it has proven value,” he said. “This study will be one of many that seeks to change how the end-user experiences and communicates pain. By helping the user understand the context of their pain and by sharing the data with clinical personnel, an app can help providers better engage those patients with meaningful interventions.”

Dr. Marovino said he was not surprised that both pain catastrophizing and anxiety were significantly reduced with app use. “I was more surprised that not all 5 measures were different in those who used the app for the longer time interval versus the control group,” he noted. “The challenge I have with this study is the sparse detail the authors provided under the heading ‘Recruitment,’ where I expected an accounting of how prospective patients first became aware of this study and how they were then approached and selected,” he said.

Specifically, “The authors provided detail on registration of patients, but this would have been after they were selected. My concern is that if the patients self-selected their own grouping (app versus non-app), there could be a real difference between those who chose the app versus those who did not in terms of health literacy, health behaviors, motivation, beliefs, expectations, and values, wherein other factors might be responsible for the observed changes or findings this study reports,” he explained.

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Can Health Apps Improve Healthcare Disparities in Pain Management and Patient Education?

Dr. Marovino’s point touches on the disparities – including racial and economic disparities– that exist across all aspects of pain management and access to healthcare in general. Potential barriers to widespread use of an app for pain management are the same as those for any health-related problem; they include ease of use, accessibility (ie, Wi-Fi, smartphones) and privacy concerns, he said. Although Dr. Marovino has no direct experience with the Manage My Pain app, he observed that other barriers include the age-old issues of patient participation, medication adherence, and engagement. For everyone, when it comes to health, “the list of things we should do, but don’t do, is lengthy,” he said.

To help overcome barriers to use of a pain management or health app, “I think we need to see more research on factors that drive and shape behaviors,” said Dr. Marovino. “There is little value in demonstrating efficacy of an intervention if only a few will use the technology.”

“The most powerful forces driving health behavior change in patients are physicians,” Dr. Marovino emphasized. “They must begin to expand their dialogue with patients to include not only medication, surgery, injections, and pain-related procedures, but also how to effectively utilize community partners for weight loss, smoking cessation, stress management, and regular exercise including strength training for seniors. These are all pain modifiers, and the use of an app can be part of the overall effort in patients’ self-care and push toward taking greater responsibility in their own health status,” he said.

There are benefits to app use, however, including potential improvement of patient-provider communication and the empowerment of patients to manage their pain experience, Dr. Marovino noted. “I tend to agree that many of the activities and interventions for chronic pain patients can be done at home by them, versus done to them by a clinical provider. This and other apps would be useful in assisting patients to monitor, understand, and communicate their pain,” he noted.

Future Apps Need to Integrate Pain Management Models, User Journeys, Underserved Patients

As we look to future pain management models and self-care,More research is needed across the various domains and dimensions of pain, including a paradigm shift that recognizes the value of qualitative methods [of assessment] – such as narrative inquiry, semi-structured interviews, and thematic analysis – to gain a deeper, patient-centered understanding of their pain journeys,” said Dr. Marovino.

Digital health solutions and health apps that recognize that pain is complex have the potential to have multiple and interacting influences across the biopsychosocial domain and within the context of the environment, noted Dr. Marovino. “Many factors can impact the expression of pain including affect, emotion, events, memory, learning, beliefs, and values, not to mention the constellation of anatomical/physiological variables and variants that contribute, influence, mitigate, and/or perpetuate the pain response,” he added.

In addition, research is needed to better identify factors that drive behavior change in chronic pain patients, he said. Dr. Marovino proposed, for example, the benefits of multiple regression modeling (MRM) to study the value of a specific app in pain management.

This type of study design allows researchers to “examine the effects of many independent variables simultaneously, and then also look at which of those variables has the most influence on the dependent variable (such as app use). It would be beneficial at this point to know who is most likely to use an app, and the predictive value in a regression approach could be useful in identifying these individuals,” he said.

Disclosures: Bhatia’s study was supported by the Department of Anesthesia and Pain Medicine at the University Health Network, Toronto, Ontario, Canada. Author TJ is the founder and CEO of ManagingLife Inc, the owner of Manage My Pain. The other authors declare no competing interests or conflicts of interest.Dr. Marovino had no financial conflicts to disclose.

Last updated on: March 19, 2021
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