E-Pain Technologies: Current State and Future Outlook

What are e-pain technologies?

E-pain technologies are internet-based or mobile device-based pain management interventions that consist of:

1. Psychological or activity-based treatments that are focused on managing pain
2. Pain symptom diaries, usually available on mobile device apps
3. Wearable devices that collect real-time data on a patient’s exercise, sleep, and other physiological data

Brian E. McGuire, PhD, from the National University of Ireland, and Patrick J. McGrath, PhD, from the IWK Health Centre in Halifax, Nova Scotia, Canada, conducted a review of e-pain technologies.¹

The researchers noted that a combination of internet- and mobile device-based platforms to both deliver and receive patient information represents an optimal strategy for patient-centered intervention. Both types of platforms may be leveraged as follows:

Internet-based interventions would provide platforms to:

• Provide educational and therapeutic content that patients may consult on their home computers
• Allow patients to provide responses and feedback
• Store and analyze patients’ response data using algorithm to devise appropriate treatments
• Inform future content based on patient-provided responses

Mobile-device based interventions — in tandem with internet-based interventions — would allow patients to:

• Record their symptoms on their cell phones
• Provide information about their pain, activities, medication usage, and moods
• Identify appropriate coping techniques

The researchers focused on psychological treatments in their review, and explored the current state of e-pain technologies, challenges for their development, and evidence of their effectiveness. In addition, they explored whether regulation of those technologies would be appropriate, and how patient access to them might be improved.

“We propose that there is an emerging evidence base for web-based interventions and that the next steps involve more nuanced effectiveness research, followed by credentialing and implementation,” the investigators wrote. “Mobile technologies are at an earlier stage of development — while they hold out the potential for wide-scale uptake in the future, at present there is insufficient evidence to recommend wide uptake. More research is needed on acceptability, feasibility, and effectiveness.”²

The following challenges in developing e-pain technologies were highlighted:

1. Treatment personalization. This could be achieved by integrating algorithms into e-pain technologies, allowing clinicians to tailor information presented to patients based on their feedback.³
2. Frequency of clinician contact for effective e-pain technologies. “E-pain interventions deliberately seek to minimize the ‘real-time’ involvement of clinicians, but we do not know if (or how much) therapist contact is needed or in what format, to engage patients and maximize clinical outcomes,” the researchers wrote.
3. Identification of the theoretical basis for e-pain interventions. Other than for web-based cognitive behavioral therapy and acceptance and commitment therapy interventions, few studies sought to identify the effective elements of their e-pain technologies.
4. Scientific evaluation and testing of effectiveness. Before clinicians can recommend an e-pain technology, studies need to be conducted to determine their safety and efficacy. In addition, identification of effective components, necessity and frequency of therapist contact, patient type, and cost-effectiveness are necessary.

Are e-pain technologies effective?

The researchers provide a list of past and recent studies examining web- and mobile device-based e-pain interventions, including studies in chronic pain, fibromyalgia, neck or back pain, adolescent headache, juvenile arthritis, rheumatoid arthritis, osteoarthritis, and breast cancer survivors at risk for lymphedema. Many of the results show improvements in patients’ anxiety, catastrophizing, functioning, acceptance, depression, activity limitations, intensity of symptoms, and sleep.

“In relation to mobile apps, there remains a need for studies that examine the feasibility, acceptability, and effectiveness of these interventions,” the researchers wrote. “Web-based interventions [show] a clear trend of effectiveness, with stronger evidence emerging in more recent studies — possibly due to better quality studies, better technology and treatment interface, better awareness of effective components, or a combination of these factors.”

Should e-pain technologies be regulated?

The US Food and Drug Administration (FDA) issued a guidance document providing a regulatory framework for mobile medical apps.⁴ However, some clinicians have noted that the recommended registration process would be burdensome and the pace of regulation might not keep up with the pace of technology development.⁵

Drs McGuire and McGrath propose an alternative to formal regulation for e-pain technologies, which could follow the ethical guidelines already in place for internet-mediated research and clinical interventions. However, this approach would not allow clinicians to determine the nature of effective e-pain intervention in a partiular patient. The investigators therefore recommend that e-pain technologies be evaluated and given a “stamp of approval” that clinicians and consumers can rely upon.

How can access to e-pain technology be improved?

While many programs are in use in research institutions and a number of private e-pain technologies have reached a wider audience, the researchers noted that many effective interventions remain within academic institutions, rendering the availability of e-pain interventions challenging.

Based on recommendations by the American College of Physicians, the Canadian Medical Association, and the IMS Institute for Healthcare Informatics, in addition to their own study,^6-8 the researchers proposed a list of measures that should be adopted in order to improve the quality of and access to e-pain technologies:

1. The creation of a curated list of interventions that are usable and have evidence of effectiveness
2. The endorsement of technologies by an appropriate organization, such as a professional body
3. The establishment of an infrastructure for e-technology prescribing and patient progress monitoring
4. The training of clinicians in prescribing and supervising e-pain interventions
5. The establishment of mechanisms to monetize the prescribing and monitoring of these technologies
6. The establishment of privacy and security regulations for e-pain interventions
7. The protection of prescribers and their institutions from liability associated with these technologies
8. The availability of low- or no-cost interventions
9. The assurance of e-technologies efficacy
10. The compatibility of e-technologies with existing health record systems
11. The assurance of compensation for e-technology developers, owner allowing for their maintenance, improvement, and expansion

Conclusions

“We contend that there is sufficient evidence to support the wider implementation of large-scale pragmatic clinical trials delivered via web-based programs, but there is a lack of evidence to support wider implementation of trials delivered through mobile devices. Efficacy studies of mobile-based interventions are likely to emerge over the next 2 years,” the investigators noted.

“Patients want interventions that are easy to access, secure, effective, and have minimal or no cost. Healthcare providers want interventions that they will get paid for prescribing, will help many patients, will not expose them to liability, and are easy to prescribe, eg, from within the electronic health record. E-pain technologies offer the potential to satisfy these requirements,” they concluded.

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References

1. McGuire BE, Henderson EM, McGrath J. Translating e-pain research into patient care. Pain. 2017;158(2):190-193. doi:10.1097/j.pain.0000000000000686
2. Vardeh D, Edwards RR, Jamison RN, Eccleston C. There’s an app for that: mobile technology is a new advantage in managing chronic pain. Pain: Clin Update. 2013;xxi:1-7.
3. Irvine AB, Russell H, Manocchia M, et al. Mobile-Web app to self-manage low back pain: randomized controlled trial. J Med Internet Res. 2015;17:e1.
4. US Food and Drug Administration (FDA). Mobile medical applications — guidance for industry and Food and Drug Administration staff. www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/
   UCM263366.pdf. Accessed February 16, 2017.
5. Barton AJ. The regulation of mobile health applications. BMC Med. 2012;10:1-4.
6. Daniel H, Snyder Sulmasy L. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. 2015;163:787-789.
7. Canadian Medical Association. Guiding principles for physicians recommending mobile applications to patients. https://www.cma.ca/Assets/assets-library/document/en/advocacy/cma_policy_guiding_principles_for_physicians_recommending_mobile_health_applications_to_patients_pd1-e.pdf. Accessed February 16, 2017.
8. IMS Institute for Healthcare Informatics. Patient apps for improved healthcare: From novelty to mainstream. 2013. www.imshealth.com/en/thought-leadership/ims-institute/reports/patient-apps-for-improved-healthcare. Accessed February 16, 2017.