mHealth Intervention for Improving Pain, Quality of Life, and Functional Disability in Patients With Chronic Pain: Systematic Review

Background Chronic pain (CP) is 1 of the leading causes of disability worldwide and represents a significant burden on individual, social, and economic aspects. Potential tools, such as mobile health (mHealth) systems, are emerging for the self-management of patients with CP. Objective A systematic review was conducted to analyze the effects of mHealth interventions on CP management, based on pain intensity, quality of life (QoL), and functional disability assessment, compared to conventional treatment or nonintervention. Methods PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed to conduct a systematic review of randomized controlled trials (RCTs) published in PubMed, Web of Science, Scopus, and Physiotherapy Evidence Database (PEDro) databases from February to March 2022. No filters were used. The eligibility criteria were RCTs of adults (≥18 years old) with CP, intervened with mHealth systems based on mobile apps for monitoring pain and health-related outcomes, for pain and behavioral self-management, and for performing therapeutic approaches, compared to conventional treatments (physical, occupational, and psychological therapies; usual medical care; and education) or nonintervention, reporting pain intensity, QoL, and functional disability. The methodological quality and risk of bias (RoB) were assessed using the Checklist for Measuring Quality, the Oxford Centre for Evidence-Based Medicine Levels of Evidence, and the Cochrane RoB 2.0 tool. Results In total, 22 RCTs, involving 2641 patients with different CP conditions listed in the International Classification of Diseases 11th Revision (ICD-11), including chronic low back pain (CLBP), chronic musculoskeletal pain (CMSP), chronic neck pain (CNP), unspecified CP, chronic pelvic pain (CPP), fibromyalgia (FM), interstitial cystitis/bladder pain syndrome (IC/BPS), irritable bowel syndrome (IBS), and osteoarthritis (OA). A total of 23 mHealth systems were used to conduct a variety of CP self-management strategies, among which monitoring pain and symptoms and home-based exercise programs were the most used. Beneficial effects of the use of mHealth systems in reducing pain intensity (CNP, FM, IC/BPS, and OA), QoL (CLBP, CNP, IBS, and OA), and functional disability (CLBP, CMSP, CNP, and OA) were found. Most of the included studies (18/22, 82%) reported medium methodological quality and were considered as highly recommendable; in addition, 7/22 (32%) studies had a low RoB, 10/22 (45%) had some concerns, and 5/22 (23%) had a high RoB. Conclusions The use of mHealth systems indicated positive effects for pain intensity in CNP, FM, IC/BPS, and OA; for QoL in CLBP, CNP, IBS, and OA; and for functional disability in CLBP, CMSP, CNP, and OA. Thus, mHealth seems to be an alternative to improving pain-related outcomes and QoL and could be part of multimodal strategies for CP self-management. High-quality studies are needed to merge the evidence and recommendations of the use of mHealth systems for CP management. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42022315808; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=315808

The app provides both adaptative ecological strategies and assessments to reduce patients' burden and pain episodes. It is an intervention designed to incite to be active in daily life, and to promote social influences and relationships, as well as the patients' expectations and their ability to be self-efficient. In addition, there are available telecoaching sessions about sedentary behavior and weight loss on the app. Fitbit [43] Monitoring PA c parameters Among all the features available of this commercial app, it is used for exercise monitoring and tracking daily activity (daily and long-term progress in the number of steps, calorie goals, and active time The app collects daily PA parameters, displays day-to-day activity goals, and includes a set of prescribed homebased exercise and aerobic exercises. Feedback is available at the end of each PA session, using a system of rewards to enhance engagement. The app allows the patient to modify and adjust the goals based on their health status, activities in daily living, daily PA performance, and functional progress. IMPACT [52] Monitoring PA parameters The app allows patients to enter their PA goals and activities performed in daily routines. Pain Care [41] Monitoring pain-related outcomes and PA parameters The app allows patients to enter pain episodes and intensity, and data related to their PA levels. In addition, patients can retrieve their data and adapt the setting of the reminders for requesting these data. FitBack [47] Monitoring pain-related outcomes CBT f and education The app includes 30 videos clips on basic aspects of pain and self-management, cognitive and behavioral approaches (mindfulness and relaxation, and the importance of being physically active, controlling fear beliefs) and videos clips on specific strength and stretching exercises. It also tracks the frequency and level of pain in each episode and the daily self-care activities used to manage pain. Weekly emails and messages can also be sent by the app as reminders to track pain and self-care activities. The app requests patients to record information about pain and mood states. In addition, it gives motivational messages to encourage patients to achieve their daily step goals, and it shows daily and monthly activity trends.

My Dear Knee [33]
Monitoring PA parameters Home-based PA program The app includes prescribed PA programs (type of exercise, repetitions, and preferred scheduled time) using colorful and animated images. It records exercise adherence and automatically sends alarms and notifications for each exercise session. Dr. Bath [35] Monitoring PA-related goals Education and homebased PA program The app is divided into an educational menu, which includes information about OA management and its treatment modalities, and recommendations promoting a healthy lifestyle, and an exercise module, including specific exercises related to OA treatment. It proposes preformulated goals to patients, depending on the personal profile and preferences and uses motivational strategies to reinforce adherence and health-related behaviors, including reminders and rewards. HereAfter [45] Monitoring PA parameters Education and homebased PA program The app contains PA programs based on neuromuscular leg strengthening, core stability, and performance and balance enhancement. It also provides educational sessions, including basic OA information, its treatment modalities, self-managing symptoms, and the importance of behavioral changes and maintaining a healthy lifestyle. The app sends daily emails or notifications to encourage adherence.

Rak Kao [39]
Monitoring symptoms Education and homebased PA program The app has 4 modules, including (1) knowledge of the disease, its ongoing, and symptoms; (2) treatment strategies; (3) a personalized approach according to the OA stage and severity; and (4) exercise instructions and recommendations. It contains a previous assessment to determine the OA stage, and depending on it, the app recommends a suitable type of exercises and repetitions and brief information about symptom self-management. Smartphone app [34] Education The app provides educational information related to basic OA knowledge and its causes, potential risk factors, healthy diet habits, different treatment approaches, and exercises prescribed for the OA condition.

IBS k AI Heali [36] Nutrition information and dietary plans
The app can scan menus and barcodes to give nutritional information and advice according to patient-specific diet plans and patients' preferences. It also contains a traffic light system to allow the patient to match the type of foods according to the nutritional information. Zemedy [46] CBT The app contains a total of 10 modules based on psychoeducation, CBT strategies involving relaxation training, exercises, cognitive strategies to manage stress states and catastrophizing, exposure exercises for reducing avoidance, behavioral experiments, and healthy nutritional recommendations.

CPP l
The Headspace [44] Mindfulness meditation training The app teaches mindfulness with autoguided meditation, with a 10-day basic meditation module followed by a specific pain module. It also provides basic information and training in mindfulness meditation aimed at CP.

TICA [50]
Monitoring symptoms, QoL n , and lifestyle routine Education and selfmanagement The app contains 21 video clips, which provide education health, including diet recommendations, encouragements to perform PA, meditation and yoga sessions, and hygiene and sexual advice. It also contains a menu for selfmanagement of emergent symptoms flare, with a list of questions related to pain experiences and possible causes. In addition, it records the patient's diets and life routines every week and tracks the study assessment questionnaires (QoL, pain intensity, and symptom data).