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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 24-33

Mobile applications for chronic pain management: An analysis of pain apps available in the app store


1 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Anaesthesia, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh, India

Date of Submission27-Oct-2020
Date of Decision27-Jan-2021
Date of Acceptance30-Jan-2021
Date of Web Publication27-Apr-2021

Correspondence Address:
Prof. Pallavi Ahluwalia
Department of Anaesthesia, Teerthanker Mahaveer Medical College, Moradabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_148_20

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  Abstract 

Background: There has been considerable interest in mobile and tablet technology in the field of health care. This interest has brought the area of mobile health apps, described as providing health care and health-related services through communications devices, into-sharp focus. This study aimed to assess the status of contemporary apps targeted at chronic pain assessment and management with a particular focus on patient-centered approach, criterion for pain assessment, medication assessment, targeted system, and pain management/guidance. Methodology: We searched for pain apps specific for chronic pain on the App Store for iOS devices and Google Play for Android devices. Each app store was searched using terms related to “pain,” “chronic pain,” “pain scale,” and “pain management.” Various parameters such as the name of the app, availability in operating systems (iOS or Android), download cost, creation dates, date of latest update, language, type of pathology, user rating, number of downloads, reviews, type of target population, the objective of the app and target population were explored. To explore the downloaded apps, an Excel® tool was designed for data extraction. Observations: Two hundred and fifty-four numbers of apps were identified after excluding duplicates. Forty-seven apps were included in the study that had a rating of above 4 in Google play store for further analysis. Eight out of 47 apps only did extensive pain assessment, and pain rating score was available in 14 apps. Most of the apps targeted exercise as a primary modality of management, and provided knowledge about the disease process. Few apps were based on the patients' hospital-based management and very few apps targeted yoga, integrative therapy, and trigger point as the primary modalities of management. 75% of apps targeted general pain, and only 25% were specific to an organ system. Majority of the apps were neither designed nor edited by licensed health-care providers, and there was little direct involvement by health-care professionals. Conclusion: The use of mobile devices can offer many advantages and opportunities for enhancing medical care. At present, due to the lack of evidence supporting their use, caution should be taken in the use of smartphones apps. These applications should also be assessed and regularly analyzed, and integrated with pain assessment and pain management and incorporate various integrative therapies based on available recommendations.

Keywords: Chronic pain, mobile apps, mobile health


How to cite this article:
Gupta B, Ahluwalia P. Mobile applications for chronic pain management: An analysis of pain apps available in the app store. Indian J Pain 2021;35:24-33

How to cite this URL:
Gupta B, Ahluwalia P. Mobile applications for chronic pain management: An analysis of pain apps available in the app store. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:24-33. Available from: https://www.indianjpain.org/text.asp?2021/35/1/24/314690


  Introduction Top

Smartphone applications are similar to programs running on individual computers. The interest in smartphones has introduced a new field of mobile health (mHealth). Smartphones can replace personal computers for functions, such as web browsing, document processing, video and music playing, task management, and video games, with the advantage of mobile accessibility and proximity to the consumer.[1] A mobile application, also known as a mobile app or simply an app, is a software or computer program designed to run on a mobile device.[2] Majority of the health professionals working in the existing health-care systems hold these devices in the pockets, and more than 40,000 mHealth apps are currently available for download from app stores.[3] Patients can use the applications in their own devices that are a way to develop a better relationship with their doctors, be more engaged with their health, and be more involved.

With the increasing usage and acceptance of smartphones, the app market is exponentially snowballing. Chronic pain is a significant public health problem that adversely affects the quality of life of millions of people. It is estimated that 1 in 3 people will experience chronic pain at some point.[4] Chronic pain, commonly described as pain that lasts longer than 3–6 months or beyond the usual recovery time of any injury, affects any aspect of a person's quality of life. The projected increase in the number of patients means that there will be more people dealing with the symptoms and side effects of their illness. Sleep, work, social functioning, and everyday tasks are also affected. Patients with persistent pain also experience depression, anxiety, irritability, sexual dysfunction, and reduced energy. This research aimed to assess the status of pain applications available for pain assessment and treatment, focusing on the patient-centered approach, medical evaluation, and management criteria. This is a way to analyze the current available pain mobile apps and their relevance.


  Methodology Top

This study aimed to assess the status of new apps targeted at chronic pain assessment and management, focusing on the patient-centered approach, targeted system, and management modality. The research question was as follows: Which commercially available pain-related apps for patients, caregivers, and professionals are available and being used, and what are their characteristics? Following the PICO structure, where “P” stands for the general public, patients, caregivers, and medical professionals, “I” relates to the identification of the apps, “C” refers to comparative assessment of apps available, and the “O” focuses on commercial accessibility for all users.[5] We searched for pain apps specific for chronic pain on the App Store for iOS devices and Google Play for Android devices. Each app store was searched using terms related to “pain,” “chronic pain,” “pain scale,” and “pain management.” Various parameters such as the name of the app, availability in operating systems (iOS or Android), download cost, creation dates, date of latest update, language, type of pathology, user rating, number of downloads, reviews, type of target population, the objective of the app, and target population were explored. The last search was done on October 12, 2020. We analyzed various elements of apps or tools that may improve usability and help patients in pain management.

For each app, data were extracted from the app store overview provided by the developer and from the developer website and consisted of: (1) name of app, (2) salient features, (3) App store category, (4) App price, (5) target consumer, (6) year of creation, (7) rating, (8) number of downloads, and (9) number and score of star rating reviews.

Data analysis

A quantitative and qualitative synthesis of the identified studies was carried out according to the search strategy and the identified characteristics; these were later analyzed according to frequencies(n) to facilitate data interpretation. The resulting analysis concerning these apps consisted of a description using frequencies (n) of the characteristics analyzed in the mobile devices. We excluded apps with a rating of <4, and where the number of users who rated the App was <5. To explore the downloaded apps, an Excel® tool was designed for data extraction; the data were analyzed and categorized using the following variables: The name of the app, availability in operating systems (iOS or Android), download cost, creation date, date of latest update, language, type of pain, user rating, type of target population, the objective of the app (early detection, prevention of symptoms of the disease, follow-up, diagnosis, and treatment), and target population (healthy population, the general public, patients, caregivers, and health-care professionals). The complex statistical analysis of the size of App was performed with Statistical Package for the Social Sciences version 22.0 software (SPSS, IBM Corp., Armonk, NY, US).

Observations

The App Store search revealed 336 apps, available for download in both the Google Play app store and the Apple iTunes. The analysis was carried out in India. Two hundred and fifty-four numbers of apps were identified after excluding duplicates. Forty-seven apps were included in the study that had a rating of above 4 in Google play store for further analysis [Table 1]. The various apps available for chronic pain are summarized in [Table 2]. The average size of app was 4.66 ± 0.199 Mb. A large number of apps were available for general pain, shoulder pain, abdominal pain, labor pain, knee pain, or headache. It was found that many of the commercially available apps lacked usability and had limitations, such as the absence of a rigorous scientific evaluation of the provided content and the recommendations given to patients. None of the available pain apps were comprehensive for pain management, and most of them contained only a pain diary module. [Figure 1] summarizes the salient features of various apps. [Figure 2] summarizes the rationale for therapy. None of the available apps targeted cancer pain, 8 out of 47 apps did extensive pain assessment, and pain rating score was available in 14 apps only; 23 apps were explicitly targeted to patients. Most of the apps targeted exercise as a primary modality of management, and only few provided knowledge about the disease process. Few apps were based on the patients' hospital management, and very few apps targeted at yoga, integrative therapy, and trigger point as the primary modality of management [Figure 3]. 75% of apps were confined towards general pain assessment, and only 25% were specified to a specific organ system [Figure 4]. The year of the creation of apps was between 2009 and 2019. Apps with more than a million downloads included healthy spine and stretching exercises at home (more than 10 m downloads), straight posture (more than a million downloads), and medication reminder and pill tracker (more than 1 million downloads).

Figure 1: Summary of various parameters (pain assessment, rating of pain, medication assessment etc) as assessed via pain apps

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Figure 2: Reflects various modalities of pain management (eg exercise, hospital based management, yoga, integrative therapy etc) employed by apps

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Figure 3: 75% of apps was confined toward general pain assessment, and 25% were specified to a specific organ system

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Figure 4: 89% of the available apps were free of cost and 11% had cost between 170-370rupees.( to be added in text besides reference)

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Table 1: Consort flow diagram

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Table 2: Reflecting name of app., features, target consumer, rating, number of reviews, cost, size and number of downloads

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Majority of the apps were not designed or edited by licensed health-care providers. None of the apps was specific to any age group; however, the app targeting tracking of labor pain was specific to females. There was little involvement by health-care professionals in these apps, although a few provided contact details of doctor or organization. Most of the apps incorporated self-management, significantly few involved education, and very few involved both. A direct communication or involvement with physicians was lacking in almost all of the apps.


  Discussion Top

Mobile communications technology is the fastest-growing field of the communications industry. It is estimated that there are >7.8 billion registered users of cell phones worldwide.[6] More than 40,000 health-related applications have been created, which can be downloaded for a nominal fee or free of charge.[7] This is consistent with the findings of the prospective comparative study conducted by Ngoo et al.,[8] which recorded a 55.8% rise in the number of applications from 2014 to 2017. There has been a marked rise in the number of software available on cell phones for the use of chronic pain in recent years. As per the data collected in this study, most of the apps were found to consist of a pain diary. The validity of these applications is a factor that must be taken into consideration by health practitioners who use them. Telemedicine is medicine where physicians and patients are widely separated using 2-way voice and visual communication (such as by satellite or computer). It is also described as a set of means or methods for improving health care, public health, and health education and support through telecommunications technology. In underdeveloped countries, video conferencing can be an alternative option to mobile telephones in diagnosis.[9]

Pain assessment is a complex process characterized by high variability between and within days, typically conducted by clinicians using self-reported, on-site, single, and recall-based ratings. Smartphone apps have proven to provide accurate tools to assess pain intensity and related variables from the patient's home, thus facilitating telemonitoring and contributing to the personalization of medical interventions by rapid modification of treatments for every individual telemonitoring. Collado-Borrell et al.[10] evaluated and examined the reliability of the information in mobile medical applications for cancer patients. They concluded that although there are several advantages that can be expected from these apps, nevertheless, there is a lack of information reliability, and regulations should be implemented to avoid these applications from being a safety concern. This is very significant in the medical field as new treatments are continually emerging. Knowledge can reach a more comprehensive number of individuals through the use of social networks using mobile apps. This represents an effective means of communication as long as the information is based on evidence; serious issues can arise when this is not the case.[11],[12] Smartphone apps are being developed for patients with fibromyalgia, sickle cell disease, and persistent musculoskeletal pain.

After analyzing more than 1000 healthcare-related apps, the reviewers concluded that most of these apps were not useful. However, the study suggested that apps that offer personal guidance based on patient data with communication and support from medical professionals may increase patient participation levels.[13] Previous studies have shown that the app-based research was mainly carried out with young people, a group that is less likely to be affected by diseases or limitations than the older population.[14] Therefore, caution is warranted while analyzing mobile applications in the health sciences.

Blödt et al.[15] reported that pain lasted for fewer days in patients using apps, and they needed less pain medication than the control group. Blödt et al. and Oldenmenger et al.,[15],[16] reported improvement of pain using the app but Raj et al. did not find any improvement using apps.[2] Furthermore, a statistically significant reduction was seen in momentary pain, total pain interference (e.g., general activity or mood), and pain catastrophizing was seen in study by Jamison et al.[2] Anxiety decreased in patients using the app in 2 trials by Raj et al. and Guétin et al.,[17],[18] although there was no decrease in anxiety level in another study.[2] Stinley et al.[3] reported only brief reduction in anxiety levels, in the subset of highly anxious patients. Guillory et al.[19] observed substantial changes in pain interference with general activities, and sleep, thus, a positive effect in app users relative to the control group during the intervention period. However, 1 week after the intervention time, sleeping pain and positive results were no longer significant. Statistically significant changes in functionality, well-being, efficiency, and appearance at work have been identified for the treatment group compared to the control group by Irvine et al.[4] Jamison et al. found that age, ethnicity, and gender did not influence app compliance or satisfaction.[2] Due to the heterogeneity between the original studies-patient characteristics, app content, and study setting-the results were not summarized using statistical methods.

Self-reported pain questionnaires and conventional paper-based have limited efficiency and accuracy. Patients with acute pain need to be treated carefully to prevent abuse of pain medication, particularly the abuse of opioids, and to avoid conversion to chronic pain.[20] Particularly, under-medicated patients under-reported their pain, possibly due to anxiety. Such limitations call for a more efficient and accurate method in pain reporting and management.

Patient-centered apps help connect patients and clinicians in real-time to address many issues related to disease progression and symptom management. These apps can work at various inpatient management levels, starting from pre-operative assessment, optimization, pain management, other symptom-based management, stress reduction, yoga, meditation, and integrative management.[20] Most of the users downloaded exercise-based apps and apps which provided them reminders to take their medications. Apps with more than a million downloads included healthy spine and straight posture (more than a million downloads), stretching exercises at home (>10 m downloads), and medication reminder and pill tracker (>1 million downloads).

None of the pain apps in the play store were found to give special emphasis/section on caregivers. Caring for the caregivers, who are dealing with patients with chronic pain, is also essential, as they can watch the patients for signs of distress, confusion, dizziness, vomiting, etc., a standard approach to system management can be incorporated in an app-based system, starting from symptomatology assessment, next step in management and so on, in a stepwise approach. Caregivers can notice subtle signs of moaning, grimacing, tension on the face, and can check for dizziness secondary to drug intake, unusual vomiting, constipation, or diarrhea, etc. If the patient forgets, caregivers can track medications to avoid over or under-dosing. They can involve patients in activities to distract them can help them to go through app-based management. Another consideration in the app reviews, the high costs, was not recognized in our study because most of the pain apps were free, except five apps that only cost between Rs. 170 and 370.

We could not find any app which verified their content or authenticated/validated their material. We feel there should be a special section for validating health-based apps, which will also enhance the credibility of the apps concerned. It is the need of the hour to have an integrated pain app, which will provide not only specific system-based assessment, but also a stepwise approach to pain, other symptoms associated, the system involved, medications, allergies, integrative therapy, and many more aspects of chronic pain management based on available recommendations and guidance. Consequently, high-quality studies for the evaluation of the efficacy of these new apps will be required. These applications should also be assessed and regularly analyzed. Thus, it is essential to develop applications that are funded by health organizations, not only for research purposes but also to provide on-going support to patients, health-care practitioners, and pain care providers. In managing patients with pain, applications can provide patients with a wide range of features, such as pain diary, educational features, reminders, treatment recommendations, and direct communication with health-care personnel in a single mobile app. Such emerging developments can be implemented in the near future and their validation and usability testing are critical. There is also a need for more high-quality research to test the effectiveness of these new handy tools. In addition, our analysis has shown that there is a lack of standardized pain assessment in many applications, and it would therefore be desirable for the scientific community to agree on a standardized pain assessment protocol and then develop an effective user-friendly and useful app. In addition, there is a need for detailed reporting of the structure, data assessment and functions of the apps and studies to investigate the elements.

Limitations

The main limitation of this analysis is the heterogeneity of the included apps for the derivation of study results. This, however, allows existing data to be represented in general without any selection bias. Furthermore, apps are a new element in mHealth, and they are still developing. Indeed, apps were only made available to a vast population in 2008 and 2009 when the Apple App Store and Google Play for Android were launched, respectively. We have tried to compensate for this limitation by presenting a well-balanced, comprehensive, and qualitative analysis of the included apps. Another limitation was the inclusion of apps with ratings of 4.0 or more. Many apps may still be in their initial phase and may not have enough ratings to be included in our study.


  Conclusion Top

Thus, it can be concluded that mobile devices can offer many advantages and opportunities for enhancing medical care. The systematic and continuous evaluation of information technology is essential since this process will contribute to the effectiveness and improvement of current and future health information systems apps are also required to be targeted for specific age groups. At present, due to the lack of evidence supporting their use, caution should be taken in the use of smartphones, social networks, and websites. These applications should also be assessed and regularly analyzed by health-care professionals, and integrated into pain assessment and management and incorporate various integrative therapies based on available recommendations.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.



 
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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