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PreprintCited by 67Opioid Use Disorder TreatmentMindfulness and Compassion InterventionsMobile Health and mHealth Applications

Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial (Preprint)

Open access
Anthony, Chris A, Rojas, Edward Octavio, Keffala, Valerie, Glass, Natalie Ann, Shah, Apurva S, Miller, Benjamin J, Hogue, Matthew, Willey, Michael C +2 more·2020·Journal of Medical Internet Research
DOI 10.2196/preprints.17750PMC PMC7458063

Preprint — published as 10.2196/17750 · Paper page

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Abstract

BACKGROUND: Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain. OBJECTIVE: This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries. METHODS: Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups. RESULTS: A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone–based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04). CONCLUSIONS: In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference. CLINICALTRIAL: ClinicalTrials.gov NCT03991546; https://clinicaltrials.gov/ct2/show/NCT03991546

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Written from the paper’s full text.

TL;DR

In adults with orthopedic trauma undergoing operative fixation, an ACT-based intervention delivered by automated mobile phone messaging for 2 weeks postoperatively reduced opioid tablet and MME consumption and was associated with lower pain intensity/interference versus no messages. The authors conclude the intervention may decrease acute postoperative opioid use, though the PRO differences likely were not clinically important.

Key findings

  • Among 76 completers (38 ACT, 38 control), the ACT group used a mean of 26.1 (SD 21.4) opioid tablets versus 41.1 (SD 22.0) in controls, a 36.5% reduction (P=.004); Table 5 reports 26.2 tablets and a 37% decrease.
  • ACT participants consumed a mean of 199.9 (SD 163.2) MME versus 307.0 (SD 166.0) in controls, a 34.9% reduction (P=.006).
  • At 2-week follow-up, ACT participants reported lower PROMIS Pain Intensity 3A scores (mean 45.9, SD 7.2) than controls (mean 49.7, SD 8.8; P=.04) and lower Pain Interference 8A scores (mean 56.6, SD 9.4 vs 60.6, SD 8.2; P=.05; Table 6 P=.048).
  • No differences were observed in PROMIS Pain Intensity 1A or Emotional Distress-Anxiety 8A, and no differences were found in opioid tablets prescribed at discharge (ACT 58.8 vs control 61.6).

Methods

  • Single-center randomized controlled trial at a university hospital level 1 trauma center. Adults with traumatic upper or lower extremity fracture undergoing operative fixation and using mobile phone text messaging were randomized 1:1 to twice-daily ACT-based mobile messages on postoperative days 1–14 or to no messages; 82 enrolled and 76 completed.
  • Primary outcome was opioid pain medication consumed; secondary outcomes were net changes from baseline PROMIS PRO scores at 2 weeks. Opioid use was assessed by pill count, daily log, or estimate; PROs were converted to t-scores.
  • Between-group comparisons used t tests or Wilcoxon rank-sum tests for continuous variables and chi-square or exact tests for categorical variables. Power analyses required 74 subjects for a 30% opioid-use decrease and 36 subjects for a 10-point PROMIS t-score difference.

Limitations

  • Paper-stated: single level 1 trauma center may limit reproducibility; extensive exclusion criteria may limit generalizability; research assistants and participants were not blinded, risking response/reporting bias; retrospective chart review for comorbidities and preoperative opioid prescriptions may be incomplete.
  • Evident from the text: discharge opioid prescriptions were not standardized between groups; follow-up was only 2 weeks with a single postoperative assessment; controls received no messages, so nonspecific messaging effects were not isolated; the sample was predominantly White and selected for mobile phone text-messaging use.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.2196/preprints.17750

Cites

37 of 37 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 49 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).

    “The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).”
    Quote in the paperSubstantial claim
  • Findingown data

    At 2-week follow-up, the intervention group reported lower postoperative PROMIS Pain Interference 8A scores (mean 56.6, SD 9.4) compared with the control group (mean 60.6, SD 8.2; P=.05).

    “At 2-week follow-up, the intervention group subjects reported lower postoperative PROMIS Pain Intensity 3A (mean 45.9, SD 7.2) and Pain Interference 8A (mean 56.6, SD 9.4) scores compared with the control group’s postoperative Pain Intensity 3A (mean 49.7, SD 8.8; P=.04) and Pain Interference 8A scores (mean 60.6, SD 8.2; P=.05; Table 6).”
    Quote in the paperSubstantial claim
  • Findingown data

    No differences were observed between groups at 2-week follow-up in the PROMIS Emotional Distress-Anxiety 8A form.

    “No differences were observed between groups at 2-week follow-up in the PROMIS Pain Intensity 1A or PROMIS Emotional Distress-Anxiety 8A forms (Table 6).”
    Quote in the paperNot a substantial claim
  • Findingown data

    At 2-week follow-up, the intervention group reported lower postoperative PROMIS Pain Intensity 3A scores (mean 45.9, SD 7.2) compared with the control group (mean 49.7, SD 8.8; P=.04).

    “At 2-week follow-up, the intervention group subjects reported lower postoperative PROMIS Pain Intensity 3A (mean 45.9, SD 7.2) and Pain Interference 8A (mean 56.6, SD 9.4) scores compared with the control group’s postoperative Pain Intensity 3A (mean 49.7, SD 8.8; P=.04) and Pain Interference 8A scores (mean 60.6, SD 8.2; P=.05; Table 6).”
    Quote in the paperSubstantial claim
  • Findingown data

    No differences were observed between groups at 2-week follow-up in the PROMIS Pain Intensity 1A form.

    “No differences were observed between groups at 2-week follow-up in the PROMIS Pain Intensity 1A or PROMIS Emotional Distress-Anxiety 8A forms (Table 6).”
    Quote in the paperNot a substantial claim
  • May combine two claims. 22
  • Classified as probably not a substantial claim. 28
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% less tablets used by subjects receiving the mobile phone-based ACT intervention (P=.004).

    “The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone–based ACT intervention (P=.004).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    A total of 82 subjects were enrolled in the study.

    “A total of 82 subjects were enrolled in the study.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The mean opioid tablet use for subjects in the ACT-based intervention group was 26.1 (SD 21.4) tablets, whereas the control group used a mean of 41.1 (SD 22.0) tablets, resulting in 36.5% fewer tablets used by the ACT group (P=.004).

    “The mean opioid tablet use for subjects in the ACT-based intervention group was 26.1 (SD 21.4) tablets, whereas the control group used a mean of 41.1 (SD 22.0) tablets, resulting in 36.5% less tablets used by subjects receiving the ACT-based intervention (P=.004; Table 5).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Subjects in the intervention group consumed a mean of 199.9 (SD 163.2) morphine milliequivalents, whereas control group subjects consumed a mean of 307.0 (SD 166.0) morphine milliequivalents, indicating 34.9% less morphine milliequivalents used by the intervention group (P=.006).

    “Similarly, subjects in the intervention group consumed a mean of 199.9 (SD 163.2) MME, on average, whereas the control group subjects consumed a mean of 307.0 (SD 166.0) MME, indicating 34.9% less MME used by subjects in the intervention group (P=.006; Table 5).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The goal of ACT is to augment an individual's psychological flexibility, thus improving their life according to 6 core cognitive processes: acceptance, defusion, contact with the present moment, self-as-context, values, and committed action.

    “The goal of ACT is to augment an individual’s psychological flexibility, thus improving their life according to 6 core cognitive processes: acceptance, defusion, contact with the present moment, self-as-context, values, and committed action (Table 1) [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] Batten S Essentials of Acceptance and Commitment Therapy 2011 London, UK Sage Publications source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Acceptance and commitment therapy (ACT) is a cognitive contextual behavioral therapy that employs a pragmatic approach to help individuals decrease pain and live according to self-identified personal values.

    “Acceptance and commitment therapy (ACT) is a cognitive contextual behavioral therapy that employs a pragmatic approach to help individuals decrease pain and live according to self-identified personal values [11,12].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] Batten S Essentials of Acceptance and Commitment Therapy 2011 London, UK Sage Publications source

      Not checked in the free run.

    • cites [12] Hayes S Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies - republished article Behav Ther 2016 11 47 6 869 85 10.1016/j.beth.2016.11.006 27993338 27993338 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The opioid pain medications administered at discharge were not standardized between study groups.

    “Owing to the changes in health care teams, staff preferences, and allergies, the opioid pain medications administered at discharge were not standardized between study groups.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    These data demonstrate that ACT-based automated mobile messaging protocols may be effective in reducing the amount of opioid medication used and may positively affect postoperative patient-reported outcomes in patients undergoing operative fixation of acute fractures.

    “These data demonstrate that ACT-based automated mobile messaging protocols may be effective in reducing the amount of opioid medication used and may positively affect postoperative PROs in patients undergoing operative fixation of their acute fractures.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Previous studies have reported that patients who consume more opioid medication report higher pain at both short- and long-term time points, which is reflected in our findings for both PROMIS pain intensity 3A and the employed pain interference measure.

    “Previous studies have reported that patients who consume more opioid medication report higher pain at both short- and long-term time points, which is reflected in our findings for both PROMIS pain intensity 3A and the employed pain interference measure [35,36].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [35] Bot AG Bekkers S Arnstein PM Smith RM Ring D Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief Clin Orthop Relat Res 2014 8 472 8 2542 9 10.1007/s11999-014-3660-4 24777731 24777731 PMC4079891 source

      Not checked in the free run.

    • cites [36] Koehler RM Okoroafor UC Cannada LK A systematic review of opioid use after extremity trauma in orthopedic surgery Injury 2018 6 49 6 1003 7 10.1016/j.injury.2018.04.003 29704954 29704954 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Participants were randomized to either the control or intervention group using a standard web-based random number generator with a range set from 1 to 10 and a 1:1 ratio by a research assistant.

    “Participants were randomized to either the control or intervention group using a standard web-based random number generator with a range set from 1 to 10 and a 1:1 ratio by a research assistant.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Prior work has demonstrated a quicker time to opioid cessation and a decrease in postoperative opioid utilization (14% less in the ACT group) when used in office ACT-based treatments.

    “Prior work has demonstrated a quicker time to opioid cessation and a decrease in postoperative opioid utilization (14% less in the ACT group) when used in office ACT-based treatments [17,18].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [17] Dindo L Zimmerman MB Hadlandsmyth K StMarie B Embree J Marchman J Tripp-Reimer T Rakel B Acceptance and commitment therapy for prevention of chronic postsurgical pain and opioid use in at-risk veterans: a pilot randomized controlled study J Pain 2018 10 19 10 1211 21 10.1016/j.jpain.2018.04.016 29777950 29777950 PMC6163061 source

      Not checked in the free run.

    • cites [18] Abid Azam M Weinrib AZ Montbriand J Burns LC McMillan K Clarke H Katz J Acceptance and commitment therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto general hospital transitional pain service Can J Pain 2017 6 28 1 1 37 49 10.1080/24740527.2017.1325317 PMC8730651 35005340 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Previous studies have found that orthopedic trauma patients use a decreasing amount of opioid medication in the first 2 postoperative weeks, with 6-15 days being the optimal opioid use period.

    “Previous studies have found that orthopedic trauma patients use a decreasing amount of opioid medication in the first 2 postoperative weeks, with 6-15 days being the optimal opioid use period [4,5].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [4] Anthony CA Volkmar A Shah AS Willey M Karam M Marsh JL Communication with orthopedic trauma patients via an automated mobile phone messaging robot Telemed J E Health 2018 7 24 7 504 9 10.1089/tmj.2017.0188 29261036 29261036 source

      Not checked in the free run.

    • cites [5] Scully RE Schoenfeld AJ Jiang W Lipsitz S Chaudhary MA Learn PA Koehlmoos T Haider AH Nguyen LL Defining optimal length of opioid pain medication prescription after common surgical procedures JAMA Surg 2018 1 1 153 1 37 43 10.1001/jamasurg.2017.3132 28973092 28973092 PMC5833616 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The National Institutes of Health developed the PROMIS tools to advance patient-reported outcomes by creating question banks that could be used for many major health issues.

    “The National Institutes of Health developed the PROMIS tools to advance PROs by creating question banks that could be used for many major health issues [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] Ader DN Developing the patient-reported outcomes measurement information system (PROMIS) Med Care 2007 5 45 Suppl 1 S1 2 10.1097/01.mlr.0000260537.45076.74 17443116 PMC2829758 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A separate power analysis determined that a total of 36 subjects would provide 80% power to detect a 10-point difference (1 standard deviation) in t-scores for the PROMIS instruments at an alpha level of .05.

    “A separate power analysis was calculated for the PRO portion of the study, and it was determined that a total of 36 subjects would provide 80% power to detect a 10-point difference (1 standard deviation) in t-scores for the PROMIS instruments at an alpha level of .05.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Traditional ACT interventions require a clinic-based, interdisciplinary team approach, which is not always feasible for both patients and health care systems.

    “However, traditional ACT interventions require a clinic-based, interdisciplinary team approach, which is not always feasible for both patients and health care systems [17,18].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [17] Dindo L Zimmerman MB Hadlandsmyth K StMarie B Embree J Marchman J Tripp-Reimer T Rakel B Acceptance and commitment therapy for prevention of chronic postsurgical pain and opioid use in at-risk veterans: a pilot randomized controlled study J Pain 2018 10 19 10 1211 21 10.1016/j.jpain.2018.04.016 29777950 29777950 PMC6163061 source

      Not checked in the free run.

    • cites [18] Abid Azam M Weinrib AZ Montbriand J Burns LC McMillan K Clarke H Katz J Acceptance and commitment therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto general hospital transitional pain service Can J Pain 2017 6 28 1 1 37 49 10.1080/24740527.2017.1325317 PMC8730651 35005340 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patient-reported outcomes, such as PROMIS, allow patients to quantify aspects of their orthopedic condition in a standardized fashion.

    “PROs, such as PROMIS, allow patients to quantify aspects of their orthopedic condition in a standardized fashion [6,7].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] Deshpande PR Rajan S Sudeepthi BL Nazir CP Patient-reported outcomes: a new era in clinical research Perspect Clin Res 2011 10 2 4 137 44 10.4103/2229-3485.86879 22145124 22145124 PMC3227331 source

      Not checked in the free run.

    • cites [7] Ahmed S Berzon RA Revicki DA Lenderking WR Moinpour CM Basch E Reeve BB Wu AW International Society for Quality of Life Research The use of patient-reported outcomes (PRO) within comparative effectiveness research: implications for clinical practice and health care policy Med Care 2012 12 50 12 1060 70 10.1097/MLR.0b013e318268aaff 22922434 22922434 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    Ethical approval of this study was provided by the University of Iowa institutional review board, and the study was determined to be Health Insurance Portability and Accountability Act compliant.

    “Ethical approval of this study was provided by the University of Iowa institutional review board, and the study was determined to be Health Insurance Portability and Accountability Act compliant.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patient-reported outcomes allow patients to quantify aspects of their orthopedic condition in a standardized fashion.

    “Patient-reported outcomes (PROs) allow patients to quantify aspects of their orthopedic condition in a standardized fashion [6,7].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] Deshpande PR Rajan S Sudeepthi BL Nazir CP Patient-reported outcomes: a new era in clinical research Perspect Clin Res 2011 10 2 4 137 44 10.4103/2229-3485.86879 22145124 22145124 PMC3227331 source

      Not checked in the free run.

    • cites [7] Ahmed S Berzon RA Revicki DA Lenderking WR Moinpour CM Basch E Reeve BB Wu AW International Society for Quality of Life Research The use of patient-reported outcomes (PRO) within comparative effectiveness research: implications for clinical practice and health care policy Med Care 2012 12 50 12 1060 70 10.1097/MLR.0b013e318268aaff 22922434 22922434 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Automated mobile phone messaging robots are low-cost tools that can deliver predefined text-based information and receive incoming responses with high reliability when patients either prefer it or it is necessary to communicate at distance.

    “Software-driven, automated mobile phone messaging robots (also called chatbots or conversational agents) are low-cost tools that can deliver predefined text-based information and receive incoming responses with high reliability when patients either prefer it or it is necessary to communicate at distance [19,23].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [19] Anthony CA Lawler EA Ward CM Lin IC Shah AS Use of an automated mobile phone messaging robot in postoperative patient monitoring Telemed J E Health 2018 1 24 1 61 6 10.1089/tmj.2017.0055 28622079 28622079 source

      Not checked in the free run.

    • cites [23] Scott EJ Anthony CA Rooney P Lynch TS Willey MC Westermann RW Mobile phone administration of hip-specific patient-reported outcome instruments correlates highly with in-office administration J Am Acad Orthop Surg 2020 1 1 28 1 e41 6 10.5435/JAAOS-D-18-00708 31860543 31860543 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Previous investigations have used automated mobile phone messaging robots to deliver patient-reported outcomes, improve communication with patients, deliver postoperative orthopedic care, and inquire about pain and opioid utilization.

    “Previous investigations have used automated mobile phone messaging robots to deliver PROs [20,23], improve communication with patients [27,31], deliver postoperative orthopedic care [32], and inquire about pain and opioid utilization [4,19,33].”
    Quote in the paperNot a substantial claim0 of 5 sources checked
    • cites [20] Anthony CA Lawler EA Glass NA McDonald K Shah AS Delivery of patient-reported outcome instruments by automated mobile phone text messaging Hand (N Y) 2017 11 12 6 614 21 10.1177/1558944716672201 29091492 29091492 PMC5669321 source

      Not checked in the free run.

    • cites [23] Scott EJ Anthony CA Rooney P Lynch TS Willey MC Westermann RW Mobile phone administration of hip-specific patient-reported outcome instruments correlates highly with in-office administration J Am Acad Orthop Surg 2020 1 1 28 1 e41 6 10.5435/JAAOS-D-18-00708 31860543 31860543 source

      Not checked in the free run.

    • cites [27] Day MA Anthony CA Bedard NA Glass NA Clark CR Callaghan JJ Noiseux NO Increasing perioperative communication with automated mobile phone messaging in total joint arthroplasty J Arthroplasty 2018 1 33 1 19 24 10.1016/j.arth.2017.08.046 29017803 29017803 source

      Not checked in the free run.

    • cites [31] Goz V Anthony C Pugely A Lawrence B Spina N Brodke D Spiker WR Software-based postoperative communication with patients undergoing spine surgery Global Spine J 2019 2 9 1 14 17 10.1177/2192568217728047 30775203 30775203 PMC6362547 source

      Not checked in the free run.

    • cites [32] Tofte JN Anthony CA Polgreen PM Buckwalter JA Caldwell LS Fowler TP Ebinger T Hanley JM Dowdle SB Holte AJ Arpey NC Lawler EA Postoperative care via smartphone following carpal tunnel release J Telemed Telecare 2020 5 26 4 223 31 10.1177/1357633X18807606 30428766 30428766 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The study was registered with ClinicalTrials.gov (NCT03991546) and reporting is consistent with the Consolidated Standards of Reporting Trials guidelines.

    “This randomized controlled trial was registered with ClinicalTrials.gov (NCT03991546) and reporting is consistent with the Consolidated Standards of Reporting Trials guidelines (Multimedia Appendix 1) [29].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Eysenbach G CONSORT-EHEALTH Group CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions J Med Internet Res 2011 12 31 13 4 e126 10.2196/jmir.1923 22209829 22209829 PMC3278112 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Automated mobile phone messaging has proved effective in collecting pain and opioid medication data from patients following orthopedic trauma and hand procedures.

    “and collecting pain and opioid medication data from patients following orthopedic trauma and hand procedures [4,19].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [4] Anthony CA Volkmar A Shah AS Willey M Karam M Marsh JL Communication with orthopedic trauma patients via an automated mobile phone messaging robot Telemed J E Health 2018 7 24 7 504 9 10.1089/tmj.2017.0188 29261036 29261036 source

      Not checked in the free run.

    • cites [19] Anthony CA Lawler EA Ward CM Lin IC Shah AS Use of an automated mobile phone messaging robot in postoperative patient monitoring Telemed J E Health 2018 1 24 1 61 6 10.1089/tmj.2017.0055 28622079 28622079 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Subjects and the enrolling research assistant were not blinded to the participant's study group following randomization.

    “Owing to the nature of this study, subjects and the enrolling research assistant were not blinded to the participant’s study group following randomization.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Automated mobile phone messaging technology demonstrates high efficacy as part of the treatment of conditions ranging from hypertension to substance abuse.

    “This technology demonstrates high efficacy as part of the treatment of conditions ranging from hypertension to substance abuse [24-26]”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [24] Anthony C Polgreen L Chounramany J Foster E Goerdt C Miller M Suneja M Segre AM Carter BL Polgreen PM Outpatient blood pressure monitoring using bi-directional text messaging J Am Soc Hypertens 2015 5 9 5 375 81 10.1016/j.jash.2015.01.008 25771023 25771023 source

      Not checked in the free run.

    • cites [25] Berrouiguet S Baca-García E Brandt S Walter M Courtet P Fundamentals for future mobile-health (mhealth): a systematic review of mobile phone and web-based text messaging in mental health J Med Internet Res 2016 6 10 18 6 e135 10.2196/jmir.5066 27287668 27287668 PMC4920962 source

      Not checked in the free run.

    • cites [26] Hall AK Cole-Lewis H Bernhardt JM Mobile text messaging for health: a systematic review of reviews Annu Rev Public Health 2015 3 18 36 393 415 10.1146/annurev-publhealth-031914-122855 25785892 25785892 PMC4406229 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Previous studies have used a 2-week postoperative period to assess opioid medication consumption in surgical patients.

    “In line with these findings, previous studies have used a 2-week postoperative period to assess opioid medication consumption in surgical patients [4].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Anthony CA Volkmar A Shah AS Willey M Karam M Marsh JL Communication with orthopedic trauma patients via an automated mobile phone messaging robot Telemed J E Health 2018 7 24 7 504 9 10.1089/tmj.2017.0188 29261036 29261036 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Automated mobile phone messaging has proved effective in increasing perioperative communication after hip and knee arthroplasty.

    “and it has also proved effective in increasing perioperative communication after hip and knee arthroplasty [27]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Day MA Anthony CA Bedard NA Glass NA Clark CR Callaghan JJ Noiseux NO Increasing perioperative communication with automated mobile phone messaging in total joint arthroplasty J Arthroplasty 2018 1 33 1 19 24 10.1016/j.arth.2017.08.046 29017803 29017803 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Automated mobile phone messaging robots have been validated in the collection of PROs in patients undergoing orthopedic hand and hip preservation procedures.

    “In addition, automated mobile phone messaging robots have been validated in the collection of PROs in patients undergoing orthopedic hand [20] and hip preservation procedures [23].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [20] Anthony CA Lawler EA Glass NA McDonald K Shah AS Delivery of patient-reported outcome instruments by automated mobile phone text messaging Hand (N Y) 2017 11 12 6 614 21 10.1177/1558944716672201 29091492 29091492 PMC5669321 source

      Not checked in the free run.

    • cites [23] Scott EJ Anthony CA Rooney P Lynch TS Willey MC Westermann RW Mobile phone administration of hip-specific patient-reported outcome instruments correlates highly with in-office administration J Am Acad Orthop Surg 2020 1 1 28 1 e41 6 10.5435/JAAOS-D-18-00708 31860543 31860543 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Mobile phone messaging robots introduce delivery of health care that lacks human interaction with unknown effects.

    “Although mobile phone messaging robots (Chat bots) provide the benefit of communicating with patients at distance with no need for human intervention, they do introduce delivery of health care that lacks human interaction with unknown effects [28].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Jones KR Lekhak N Kaewluang N Using mobile phones and short message service to deliver self-management interventions for chronic conditions: a meta-review Worldviews Evid Based Nurs 2014 4 11 2 81 8 10.1111/wvn.12030 24597522 24597522 source

      Not checked in the free run.

  • May combine two claims. The quote only partly states this claim.

    Study design and conductown data

    There were no baseline differences between the intervention and control groups in demographic and clinical factors, including age, psychiatric diagnosis, substance abuse history, injury type, disposition following discharge, method for reporting opioid medication consumption, preoperative opioid prescriptions, and preoperative patient-reported outcomes.

    “Furthermore, no differences between groups were found for injury type, disposition following discharge, method for reporting opioid medication consumption, preoperative opioid medication prescriptions, or preoperative PROs (Table 3).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Outside of the mobile messaging intervention, both groups received the same standard postoperative care, health care team communications, and instructions for completing the study follow-up.

    “Outside of the mobile messaging intervention, both groups received the same standard postoperative care, health care team communications, and instructions for completing the study follow-up.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PROMIS Pain Intensity 1A Short form, PROMIS Pain Intensity 3A Short form, PROMIS Pain Interference 8A Short form, and PROMIS Emotional Distress-Anxiety 8A Short form employ a fixed low number of questions that are highly reliable when compared with their respective domain's full item bank.

    “The PROMIS Pain Intensity 1A Short form, PROMIS Pain Intensity 3A Short form, PROMIS Pain Interference 8A Short form, and PROMIS Emotional Distress-Anxiety 8A Short form all employ a fixed low number of questions that are highly reliable when compared with their respective domain’s full item bank, making them excellent tools for both patients and clinicians [9,10].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [9] Ader DN Developing the patient-reported outcomes measurement information system (PROMIS) Med Care 2007 5 45 Suppl 1 S1 2 10.1097/01.mlr.0000260537.45076.74 17443116 PMC2829758 source

      Not checked in the free run.

    • cites [10] Cella D Choi SW Condon DM Schalet B Hays RD Rothrock NE Yount S Cook KF Gershon RC Amtmann D DeWalt DA Pilkonis PA Stone AA Weinfurt K Reeve BB PROMIS adult health profiles: efficient short-form measures of seven health domains Value Health 2019 5 22 5 537 44 10.1016/j.jval.2019.02.004 31104731 31104731 PMC7201383 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductnone given

    The study was limited to a single level 1 trauma center, which may affect the reproducibility of the results across other health care settings.

    “First, we were limited to a single level 1 trauma center, which may affect the reproducibility of our results across other health care settings.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    The difference in pain intensity and pain interference at 2 weeks most likely does not represent a clinically important difference based on the SD methodology used in prior works with PROMIS tools, but it at least suggests that the intervention group did not experience greater pain.

    “This most likely does not represent a clinically important difference based on the SD methodology used in prior works with PROMIS tools (Table 6), but it at least suggests that the intervention group did not experience greater pain [34].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Broderick JE Schneider S Junghaenel DU Schwartz JE Stone AA Validity and reliability of patient-reported outcomes measurement information system instruments in osteoarthritis Arthritis Care Res (Hoboken) 2013 10 65 10 1625 33 10.1002/acr.22025 10.1002/acr.22025 23592494 23592494 PMC3779528 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patients prefer automated mobile phone messaging for delivering and receiving medical information.

    “Evolving communication methods, such as automated mobile phone messaging [4,19-21], for health care purposes are increasingly important, as patients prefer these communication methods for delivering and receiving medical information [22].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Liu TC Ohueri CW Schryver EM Bozic KJ Koenig KM Patient-identified barriers and facilitators to pre-visit patient-reported outcomes measures completion in patients with hip and knee pain J Arthroplasty 2018 3 33 3 643 9.e1 10.1016/j.arth.2017.10.022 29169689 29169689 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Improved mood symptoms, less pain interference, and faster cessation of opioid pain medication are recognized benefits of using ACT in clinic-based, interdisciplinary approaches to pain management after surgery.

    “Improved mood symptoms, less pain interference, and faster cessation of opioid pain medication are some of the recognized benefits of using ACT in clinic-based, interdisciplinary approaches to pain management after surgery [17,18].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [17] Dindo L Zimmerman MB Hadlandsmyth K StMarie B Embree J Marchman J Tripp-Reimer T Rakel B Acceptance and commitment therapy for prevention of chronic postsurgical pain and opioid use in at-risk veterans: a pilot randomized controlled study J Pain 2018 10 19 10 1211 21 10.1016/j.jpain.2018.04.016 29777950 29777950 PMC6163061 source

      Not checked in the free run.

    • cites [18] Abid Azam M Weinrib AZ Montbriand J Burns LC McMillan K Clarke H Katz J Acceptance and commitment therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto general hospital transitional pain service Can J Pain 2017 6 28 1 1 37 49 10.1080/24740527.2017.1325317 PMC8730651 35005340 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The exclusion criteria for this study were extensive, and thus, the results may not be generalizable to the entire scope of orthopedic trauma patients.

    “Next, the exclusion criteria for this study were extensive, and thus, the results may not be generalizable to the entire scope of orthopedic trauma patients.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The research assistants were not blinded to the patients' study group.

    “The research assistants were not blinded to the patients’ study group.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The lack of blinding could potentially introduce response or reporting bias.

    “The lack of blinding could potentially introduce response or reporting bias, making this a potential area of improvement for studies seeking to follow the present methodology.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    Patients understood the outcomes of interest in this study, which could be susceptible to reporting bias.

    “In addition, patients understood the outcomes of interest in this study, which could be susceptible to reporting bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Subjects in the ACT-based intervention group also reported lower pain intensity and pain interference after 2 weeks, although this likely did not represent a clinically important difference.

    “Subjects in the ACT-based intervention group also reported lower pain intensity and pain interference after 2 weeks, although this likely did not represent a clinically important difference.”
    Quote in the paperNot a substantial claim
40 of 40

  • The paper relies on this without support.

    Patients with traumatic orthopedic injuries are at risk for prolonged opioid utilization in the postoperative period.

    “Health care teams caring for patients with traumatic orthopedic injuries have traditionally used opioid medication in the postoperative setting, and these patients are at risk for prolonged opioid utilization in the postoperative period.”

  • The paper relies on this without support.

    The effect on opioid utilization is attributable to the ACT component rather than to the mobile messaging robot or additional attention.

    “In this study, delivering an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid utilization in orthopedic trauma patients in the first 2 weeks after their injury.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Twelve studies evaluated (sub)acute outcomes, and all but two evaluated chronic outcomes.

    “Twelve studies evaluated (sub)acute outcomes, 2,7,11,12,18,21,29,32,39,44,45,55 and all but 2 studies 2,18 evaluated chronic outcomes.”

    From Can perioperative psychological interventions decrease the risk of postsurgical pain and disability? A systematic review and meta-analysis of randomized controlled trials (2022) · cites this paper as [2]

    The Methods (Outcome Measures; page unavailable) describe this trial’s outcomes at a 2-week follow-up, supporting its inclusion among studies evaluating (sub)acute outcomes. The paper does not report a chronic-outcome assessment, so it does not support counting this trial among the studies that evaluated chronic outcomes. As an individual trial, it also cannot establish the citing document’s total of twelve studies. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Previous RCTs of ACT applied perioperatively in orthopedic and breast surgery observed a decrease in pain interference and an improvement in anxiety levels.

    “Based on previous work from RCTs with ACT applied perioperatively in orthopedic and breast surgery [79,80], in which a decrease in pain interference and an improvement in anxiety levels were observed”

    From Effectiveness of Acceptance and Commitment Therapy (ACT) for the Management of Postsurgical Pain: Study Protocol of a Randomized Controlled Trial (SPINE-ACT Study) (2023) · cites this paper as [79]

    The Results > Patient-Reported Outcomes section (page unavailable) reports lower pain-interference scores in the ACT group after orthopedic trauma surgery. It explicitly reports no between-group difference in anxiety at two weeks, so this source does not support the claimed improvement in anxiety levels. The breast-surgery component is not evaluated in this paper. (LLM, conf=0.91)

    Experimental — accuracy not yet measured

  • Anthony et al. (2020) found that their AI-delivered online ACT intervention for postoperative pain resulted in users consuming 36.5% fewer opioid tablets than the control group and significantly lower postoperative pain.

    “Anthony et al. (2020) found that their AI-delivered online ACT intervention for postoperative pain, resulted in users consuming 36.5% fewer opioid tablets than the control group and significantly lower postoperative pain (41).”

    From Examining the role of AI technology in online mental healthcare: opportunities, challenges, and implications, a mixed-methods review (2024) · cites this paper as [41]

    The Results (Opioid Pain Medication Use) report 36.5% fewer opioid tablets consumed, and the Abstract Results report a significantly lower postoperative pain-intensity score (P=.04). But the Introduction (Mobile Phone Messaging Communication) describes delivery through an automated mobile-phone messaging robot using predefined texts, not an AI-delivered online intervention. The Discussion (Conclusions) also cautions that the pain difference likely was not clinically important. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • Eight studies reported ethnicity; in most studies between 31% and 91% of participants identified as White.

    “Eight studies reported on the ethnicity of the participants (30, 32, 41, 74, 76, 77, 80, 83), and in most of the studies between 31% and 91% of the participants identified as White.”

    From Examining the role of AI technology in online mental healthcare: opportunities, challenges, and implications, a mixed-methods review (2024) · cites this paper as [41]

  • The NMA for dropout considered n=6 RCTs.

    “The NMA considered n=6 RCTs (41, 73, 74, 76–78).”

    From Examining the role of AI technology in online mental healthcare: opportunities, challenges, and implications, a mixed-methods review (2024) · cites this paper as [41]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • ACT mean tablet use differs between the results text and Table 5

    Minor

    The results text gives 26.1 tablets for the ACT group, while Table 5 gives 26.2 for the same group and outcome, both to one decimal place.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. [8]Review of Physician and Advanced Practitioner Recruiting Incentives Merritt Hawkins 2019 2020-07-09 https://www.merritthawkins.com/trends-and-insights/article/reports/2019-review-of-physician-and-advanced-practitioner-recruiting-incentives/

Cited by

Sorted by citations

Related

Authors
Anthony, C. A., Rojas, E. O., Keffala, V., Glass, N. A., Shah, A. S., Miller, B. J., Hogue, M., Willey, M. C., Karam, M., & Marsh, J. L.
Affiliations
  • University of Iowa Hospitals and Clinics (US)
  • Children's Hospital of Philadelphia (US)
Corresponding author
Rojas, Edward Octavio
ORCID
Venue
Journal of Medical Internet Research
Publisher
JMIR Publications Inc.
Published
2020-01-09
Volume
22
Issue
7
Pages
e17750-e17750
ISSN
1438-8871 (ISSN-L)
DOI
10.2196/preprints.17750
PMC
PMC7458063
OpenAlex
W3027718729
Cited by
64
References
37
Citations by year
2026: 4 · 2025: 12 · 2024: 14 · 2023: 16 · 2022: 10 · 2021: 8
FWCI
6.36
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Journal of Medical Internet Research (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Digital Commons@Becker (Washington University School of Medicine) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
Orthopaedic Trauma Association
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
Keywords
acceptance and commitment therapy, text messaging, text messaging intervention, postoperative opioid use, orthopedic trauma, fracture fixation, pain intensity, patient-reported outcomes, digital health interventions, trauma center patients, postoperative pain management, digital cognitive behavioral therapy
MeSH terms
Adult, Aged, Analgesics, Opioid, Female, Humans, Male, Middle Aged, Musculoskeletal Diseases, Postoperative Period, Robotics, Cell Phone, Text Messaging, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-05.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-05.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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