CoChat
Sign Up
Cited by 38Mobile Health and mHealth ApplicationsMusculoskeletal pain and rehabilitationDigital Mental Health Interventions

Telemonitoring in Chronic Pain Management Using Smartphone Apps: A Randomized Controlled Trial Comparing Usual Assessment against App-Based Monitoring with and without Clinical Alarms

Open access
Suso-Ribera, Carlos, Castilla, Diana, Zaragozá, Irene, Mesas, Ángela, Server, Anna, Medel, Javier, García-Palacios, Azucena·2020·International Journal of Environmental Research and Public Health
DOI 10.3390/ijerph17186568PMC PMC7559749
Open this paper in CoChat — free accountOpen PDF

Abstract

Background. The usefulness of mHealth in helping to target face-to-face interventions for chronic pain more effectively remains unclear. In the present study, we aim to test whether the Pain Monitor mobile phone application (app) is well accepted by clinicians, and can help improve existent medical treatments for patients with chronic musculoskeletal pain. Regarding this last goal, we compared three treatment conditions, namely usual treatment, usual treatment with an app without alarms and usual treatment with an app with alarms. All treatments lasted one month. The three treatments were compared for all outcomes, i.e., pain severity and interference, fatigue, depressed mood, anxiety and anger. Methods. In this randomized controlled trial, the usual monitoring method (i.e., onsite; n = 44) was compared with daily ecological momentary assessment using the Pain Monitor app—both with (n = 43) and without alarms (n = 45). Alarms were sent to the clinicians in the presence of pre-established undesired clinical events and could be used to make treatment adjustments throughout the one-month study. Results. With the exception of anger, clinically significant changes (CSC; 30% improvement) were greater in the app + alarm condition across outcomes (e.g., 43.6% of patients experienced a CSC in depressed mood in the app + alarm condition, which occurred in less than 29% of patients in the other groups). The clinicians were willing to use the app, especially the version with alarms. Conclusions. The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.

AI snapshot

Written from the paper’s full text.

TL;DR

This superiority RCT compared usual episodic monitoring, app-based daily monitoring without alarms, and app-based monitoring with clinical alarms added to usual treatment for chronic musculoskeletal pain over one month. It found no significant between-group differences at the group level, but more patients in the app + alarm condition achieved clinically significant improvements on most outcomes, and clinicians accepted the app, especially with alarms.

Key findings

  • Final analyzed samples were 44 (TAU), 45 (TAU + app), and 43 (TAU + app + alarm); average daily app response was 77.0%.
  • Group-level analyses showed no significant between-group differences (all Kruskal–Wallis p > 0.01); only the TAU + app + alarm condition showed a significant reduction in pain interference (Z = −3.32, p < 0.001).
  • Clinically significant change (≥30% improvement) was consistently higher in the app + alarm condition except for anger: pain severity 33.3% vs 15.4% (TAU) and 16.7% (TAU + app); sadness/depressed mood 43.6% vs less than 29% in the other groups; anxiety 30.8% vs less than 22%.
  • Clinicians (n = 6) generally perceived the app as useful and preferred the alarm version; helping patients download/use the app took a median of 15 min, and responding to all daily alarms took a median of 27.5 min. There were 51 alarms, and 93% were considered relevant enough to call the patient.

Methods

  • Superiority RCT in adults with chronic musculoskeletal pain at a tertiary care pain unit in Barcelona (2017–2018), randomized to TAU, TAU + app, or TAU + app + alarms; all received usual medical treatment for one month.
  • The Pain Monitor Android app prompted twice-daily ecological momentary assessment for 30 days; alarms were sent to clinicians for pre-established undesired clinical events. Primary outcomes included pain severity and medication side effects; secondary outcomes included fatigue, pain interference, depression, anxiety, and anger, mostly measured with 11-point numerical rating scales.
  • Analyses included MANOVA for baseline comparability, Kruskal–Wallis and Friedman tests with alpha set to 0.01, an individual-level ≥30% clinically significant change analysis, ANOVA for side-effect frequency, and a clinician survey.

Limitations

  • The paper states sample loss and reduced power, with anticipated 10% dropout proving insufficient and at least 25% expected; it also notes reliance on subjective outcomes only, focus on musculoskeletal pain only, use of an uncorrected alpha of 0.05 (correcting to 0.01 would increase required sample from 150 to 222), no evaluation of patient technological ability, possible influence of the 30% cutoff, midpoint response issues, and no cost analysis.
  • Evident from the text: patients and treating physicians were not blinded, TAU follow-up was conducted by phone, the app was only available for Android, and daily symptoms were not assessed in the TAU condition.
  • Evident from the text: technical/phone-related problems caused nearly 20% sample loss, and the study did not include objective measures such as wearable devices.

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

Integrity signals

Registry

Crossref · 10.3390/ijerph17186568

Cites

77 of 77 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 69 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    93% of alarms were considered sufficiently relevant to call the patient and further investigate whether an action was required.

    “In total, 93% of alarms were considered sufficiently relevant to call the patient and further investigate whether an action (e.g., a change in the medication) was required.”
    Quote in the paperNot a substantial claim
  • Findingown data

    The statistical analyses did not indicate significant differences in the proportion of clinically improved patients across conditions.

    “Again, the statistical analyses did not indicate significant differences in the proportion of clinically improved patients across conditions.”
    Quote in the paperSubstantial claim
  • Findingown data

    The burden of using the app was generally perceived as low or average.

    “As reported in Table 3, the burden was generally perceived as low or average.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In the TAU + app + alarm condition, a reduction in pain interference was revealed (Z = −3.32, p < 0.001).

    “Only in the TAU + app + alarm condition a change (e.g., reduction) in pain interference was revealed (Z = −3.32, p < 0.001).”
    Quote in the paperSubstantial claim
  • Findingown data

    The physicians were keener on using the app version with alarms than the version without alarms.

    “Importantly, they were keener on using the app version with alarms than the version without alarms.”
    • Also stated in: § Abstract · plain
      “The clinicians were willing to use the app, especially the version with alarms.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 40
  • Classified as probably not a substantial claim. 40
  • The quote only partly states this claim. 1

  • May combine two claims.

    Findingown data

    Overall, the response to the prompted daily questions in the app was good, with patients responding to 77.0% of daily evaluations on average, comparable to past research.

    “Overall, the response to the prompted daily questions in app was good (on average, patients responded to 77.0% of daily evaluations) and comparable to past research [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

  • May combine two claims.

    Findingown data

    The proportion of patients showing a clinically significant change in outcomes was consistently higher in the TAU + app + alarm condition, with the exception of anger, where the numbers were similar to the TAU condition.

    “Note, however, that the proportion of patients showing a CSC in outcomes was consistently higher in the TAU + app + alarm condition, with the only exception of anger, where the numbers were similar in the previous and the TAU condition.”
    • Also stated in: § Abstract · plain
      “With the exception of anger, clinically significant changes (CSC; 30% improvement) were greater in the app + alarm condition across outcomes (e.g., 43.6% of patients experienced a CSC in depressed mood in the app + alarm condition, which occurred in less than 29% of patients in the other groups).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In total, 51 alarms were received in the TAU + app + alarm condition; the most frequent were recurrent headache (n = 11), gait instability (n = 10), interference of pain on sleep (n = 5), urine retention (n = 4), very severe pain levels that do not improve with treatment (n = 3), and sleepiness (n = 3).

    “In total, 51 alarms were received in the TAU + app + alarm condition. The most frequent were related to recurrent headache (n = 11), gait instability (n = 10), interference of pain on sleep (n = 5), urine retention (n = 4), very severe pain levels that do not improve with treatment (n = 3) and sleepiness (n = 3).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    Patients had musculoskeletal pain, most frequently pain in the low back or in the neck.

    “Patients had musculoskeletal pain, most frequently pain in the low back or in the neck.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    33.3% of patients in the TAU + app + alarm condition experienced a clinically significant reduction in pain severity after one month, compared with 15.4% in TAU and 16.7% in TAU + app.

    “For example, 33.3% of patients in the TAU + app + alarm condition experienced a CSC reduction in pain severity after one month of treatment, while only half of this proportion improved in the other two conditions (15.4 in TAU and 16.7 in TAU + app).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The pain clinic physicians (n = 6) generally perceived that the app was useful for pain management and for their own comfort as health care providers.

    “As indicated in Table 3, the pain clinic physicians (n = 6) generally perceived that the app was useful for pain management (e.g., increased treatment safety and effectiveness) and for their own comfort as health care providers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    On average, physicians perceived that helping the patient download the app and guiding them during first use required 13 min (range 7-20 min, median 15 min), and responding to all daily alarms required 28 min in total (range 10-45 min, median 27.5 min).

    “On average, the physicians perceived that helping the patient download the app and guiding them during the first use required 13 min (7–20 min range, median = 15 min) and responding to all daily alarms (e.g., looking at the patient’s medical record and calling them) required 28 min in total (10–45-min range; median = 27.5 min).”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The healthcare professionals believed that the app increased their sense of comfort as healthcare providers.

    “They also believed that it increased their sense of comfort as healthcare providers.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Depression and anxiety levels were meaningfully reduced in 43.6% and 30.8% of patients in the app plus alarm condition, while reductions in the other two conditions occurred in less than 29% and 22%, respectively.

    “depression and anxiety levels were meaningfully reduced in 43.6% and 30.8% of patients in the app + alarm condition, while reductions in depression and anxiety in the other two conditions occurred in less than 29% and 22%”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A clinically significant change in sadness was obtained by 43.6% of patients in the TAU + app + alarm condition and less than 30% of patients in the other two groups.

    “Similarly, a CSC in sadness was obtained by 43.6% of patients in the TAU + app + alarm condition and less than 30% of patients in the other two groups.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The healthcare professionals involved generally perceived that the app was useful for pain management in the sense that it improved treatment safety and effectiveness.

    “the healthcare professionals involved generally perceived that the app was useful for pain management in the sense that it improved treatment safety and effectiveness.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Comparable results were revealed for pain interference, fatigue, and anxiety, always in favor of the TAU + app + alarm condition.

    “Comparable results were revealed for pain interference, fatigue and anxiety, always in favor of the TAU + app + alarm condition.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In pain severity, 15.4% and 16.7% of patients in the TAU and TAU plus app conditions showed a clinically significant reduction, while 33.3% in the TAU plus app plus alarm condition showed such reductions.

    “while 15.4% and 16.7% of patients in the TAU and TAU + app conditions showed a clinically significant reduction in pain severity, twice the number of patients in the TAU + app + alarm condition (33.3%) showed such reductions.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Monitoring with the app and alarms did not have a significantly greater impact on outcomes compared to usual monitoring or the app without alarms, both at the group and individual level.

    “In relation to the first goal and contrary to our expectations, monitoring with the app and alarms did not have a significantly greater impact on outcomes compared to the usual monitoring method or the app without alarms condition, both at the group and individual level.”
    • Also stated in: § 4. Discussion · hedged
      “the analyses at the group level indicated that the effect of the condition was insufficient to reveal group differences with the recruited sample”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Helping patients download the app and respond to alarms required some extra time, but the healthcare professionals found this burden to be low or moderate.

    “they reported that helping patients download the app and respond to alarms required some extra time, but they found this burden to be low or moderate.”
    Quote in the paperNot a substantial claim

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

    Findingown data

    The healthcare professionals were more satisfied with and preferred the version of the app that included alarms.

    “they were more satisfied with the version of the app that included alarms.”
    • Also stated in: § 4. Discussion · plain
      “they preferred the app version that included alarms, even when these generated some burden.”
    Quote in the paperNot a substantial claim

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

    Findingcitation

    In the present study, the prevalence of midpoint responses was 8.3%, which appears to be an acceptable level of uncertainty according to past research.

    “In the present study, the prevalence of midpoint responses was 8.3%, which appears to be an acceptable level of uncertainty according to past research [80].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [80] Garland, 1991, The mid-point on a rating scale: Is it desirable, Mark. Bull.

      Not checked in the free run.

  • May combine two claims.

    Findingreasoning

    Patient daily self-monitoring eliminated the need for physician active monitoring, so only when the app algorithm detected an undesired event was the physician notified and only then was a phone call made.

    “patient daily self-monitoring eliminated the need for physician active monitoring, so only when the app algorithm detected an undesired event, this was notified to the physician and only then a phone call was made.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The missing-response alarm strategy was implemented and helped identify some technical problems, such as patients who changed their phone or were not receiving push notifications.

    “This strategy was implemented in the present investigation and it helped us identify some technical problems (e.g., patients that changed their phone or patients that were not receiving the push notifications).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    It often took several calls to get in contact with participants, and they were not always available to complete the survey at the time of the call.

    “if often took several calls to get in contact with the participants and these were not always available to complete the survey at the time of the call.”
    Quote in the paperSubstantial claim

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

    Findingnone given

    Correcting the alpha level to 0.01 due to multiple comparisons in the present study would have increased the sample size needed from 150 to 222.

    “by correcting the alpha level to 0.01 due to multiple comparisons in the present study, the sample size needed would have increased from 150 to 222.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Calling patients in the TAU condition for follow-up assessment was very time consuming and largely ineffective.

    “calling patients in the TAU condition for follow-up assessment was very time consuming and largely ineffective.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Retrospective pain assessment leads to recall bias and reduces accuracy.

    “Furthermore, retrospective pain assessment leads to recall bias and reduces accuracy [27].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Herrero, 2014, Ecological momentary assessment for chronic pain in fibromyalgia using a smartphone: A randomized crossover study, Eur. J. Pain source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Telemonitoring with episodic phone calls is resource-consuming and ineffective because such phone calls require the active participation of a healthcare professional.

    “Additionally, because such phone calls require the active participation of a healthcare professional, which makes this procedure resource-consuming and ineffective [18].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [18] Mesas, 2018, Improving pain treatment with a smartphone app: Study protocol for a randomized controlled trial, Trials source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Telemonitoring with episodic phone calls only partially solves the problems of monitoring because undesired events can occur at different treatment stages, so control calls often occur before or long after unwanted events occur.

    “Telemonitoring with episodic phone calls, which is becoming an increasingly common practice, also only partially solves the aforementioned problems. First, because undesired events (e.g., side medication effects or decreased treatment effectiveness) can occur at different treatment stages [34], which means that control calls will often occur before or long after unwanted events occur.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] Breivik, 2008, Assessment of pain, Br. J. Anaesth. source

      Not checked in the free run.

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

    Premisecitation

    The Pain Monitor app was developed by a multidisciplinary team including physicians, nurses, psychologists, and engineers following guidelines on pain research and eHealth.

    “The app, which has been developed by a multidisciplinary team including physicians, nurses, psychologists and engineers following guidelines on pain research and eHealth [38,39,40,41], was found to have valid content”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [38] Dworkin, 2005, Core outcome measures for chronic pain clinical trials: IMMPACT recommendations, Pain source

      Not checked in the free run.

    • cites [39] Rosser, 2011, Smartphone applications for pain management, J. Telemed. Telecare source

      Not checked in the free run.

    • cites [40] Kaiser, 2017, Developing a core outcome-domain set to assessing effectiveness of interdisciplinary multimodal pain therapy, Pain

      Not checked in the free run.

    • cites [41] Portelli, 2016, A quality review of smartphone applications for the management of pain, Br. J. Pain source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    This approach is problematic because some patients may tolerate serious or urgent problems for too long, while others may seek care for symptoms that are less urgent or not problematic.

    “This approach is problematic, as some patients may tolerate serious or even urgent problems (e.g., tachycardia, severe drowsiness, or persistent vomiting, diarrhea or urine retention) for too long, while others may seek care for symptoms that are less urgent or not problematic (e.g., very mild or short-term).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Societies will not be able to sustain the current model of care for chronic pain.

    “Taking all the previous into account, it has been argued that our societies will not be able to sustain the current model of care for this condition [20,21,35,36], especially due to the aging of the population and the dramatic increase in the prevalence of this disease in the elderly [9].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [20] OECD, and EU (2016). Health at a Glance: Europe 2016—State of Health in the EU Cycle, OECD Publishing.

      Not checked in the free run.

    • cites [21] Busse, R., Blümel, M., Scheller-Kreinsen, D., and Zentner, A. (2010). Tackling Chronic Disease in Europe: Strategies, Interventions and Challenges, WHO.

      Not checked in the free run.

    • cites [35] World Health Organization (2002). Innovative Care for Chronic Conditions, WHO.

      Not checked in the free run.

    • cites [36] Christensen, 2010, Using e-health applications to deliver new mental health services, Med. J. Aust.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Paper diaries are problematic due to participant noncompliance (missing data and back-filling) and errors associated with manual data entry.

    “However, research has shown that the use of paper diaries is problematic due to participant noncompliance (missing data and back-filling) and errors associated with manual data entry [28,29].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [28] MacKillop, J., and de Wit, H. (2013). Ecological Momentary Assessment. Wiley-Blackwell Handb. Addict. Psychopharmacology, John Wiley & Sons. source

      Not checked in the free run.

    • cites [29] Smyth, 2003, Ecological momentary assessment research in behavioral medicine, J. Happiness Stud. source

      Not checked in the free run.

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

    Study design and conductcitation

    The study protocol, including planned procedures and analyses, was published before starting recruitment.

    “The study protocol—including a description of the planned procedures and analyses—was published before starting the recruitment [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Mesas, 2018, Improving pain treatment with a smartphone app: Study protocol for a randomized controlled trial, Trials source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    Single items for each construct were validated against well-established measures of pain severity, pain interference, fatigue, and mood, and the correlations were significant and moderate in strength.

    “In past research, single items for each of these constructs were validated to be used in the Pain Monitor app [42].”
    • Also stated in: § 2.4. Pain Monitor App · plain
      “The correlations were found to be significant and moderate in strength.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

    • cites [53] Cleeland, 1994, Pain assessment: Global use of the brief pain inventory, Ann. Acad. Med. Singapore

      Not checked in the free run.

    • cites [54] McNair, D., Lorr, M., and Droppleman, L. (1971). Profile of Mood States, Educational and Industrial Testing Service.

      Not checked in the free run.

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

    Study design and conductnone given

    Randomization was performed by an independent researcher with an online randomization tool.

    “Randomization was performed by an independent researcher with an online randomization tool.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    An analysis of clinically meaningful improvements at the individual level was added due to insufficient power and loss in sample size.

    “Again different from that which was planned, we added an analysis of clinically meaningful improvements at the individual level due to insufficient power and loss in sample size (see the results section).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisereasoning

    The utility of the Pain Monitor app in terms of increased treatment effectiveness remains unclear.

    “While important milestones have been achieved, the utility of the app in terms of increased treatment effectiveness (e.g., further reduction in pain severity and associated symptoms) remains unclear.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Due to multiple comparisons, a more restrictive alpha level of 0.01 was set for the analyses.

    “Due to multiple comparisons, a more restrictive alpha level of 0.01 was set for the analyses.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    Sample size was calculated a priori with G*Power, expecting moderate between-group differences, with 80% power, alpha 0.05, Cohen's d of 0.5, yielding 50 participants needed per condition.

    “Sample size was calculated a priori with the statistical software G*Power [49] considering previous studies on complications of pain treatments [30,50].”
    • Also stated in: § 2.2. Participants · plain
      “Taking 80% power, an alpha level of 0.05 and an expected Cohen’s d of 0.5, we calculated that 50 participants would be needed in each condition.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [49] Faul, 2007, G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences, Behav. Res. Methods source

      Not checked in the free run.

    • cites [30] Deyo, 2009, Overtreating chronic back pain: Time to back off?, J. Am. Board Fam. Med. source

      Not checked in the free run.

    • cites [50] Furlan, 2006, Opioids for chronic noncancer pain: A meta-analysis of effectiveness and side effects, Can. Med. Assoc. J. 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 conductown data

    The study was approved by the ethical review board of Vall d'Hebron Hospital and registered on clinicaltrials.gov.

    “All procedures were approved by the ethical review board of the Vall d’Hebron Hospital in Barcelona on 25th, June 2017 and registered on clinicaltrials.gov on 25th, July 2017 (NCT03247725).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The Pain Monitor app was found to have valid content comparable to well-established paper-and-pencil measures and high patient acceptability, with response rates greater than 70% for daily responses over one month.

    “was found to have valid content (i.e., comparable to well-established paper-and-pencil measures) and high patient acceptability (i.e., response rates greater than 70% for daily responses over a period of one month) [42].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The comparability of the paper-and-pencil and app assessments was not conducted in this study because the validity of the assessment protocol across measurement modalities was already performed in past research.

    “The comparability of the paper-and-pencil and app assessments was not conducted here because the validity of the current assessment protocol across measurement modalities was already performed in past research [42].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    A reduction of 30% in severity of symptoms is a useful benchmark representing at least moderate clinically significant changes for individuals.

    “This analysis is recommended in guidelines for pain trials and a reduction in 30% of severity of symptoms is argued to be a useful benchmark, representing at least moderate clinically significant changes (CSC) for the individuals [61,62].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [61] Scott, 2014, Clinically meaningful scores on pain catastrophizing before and after multidisciplinary rehabilitation: A prospective study of individuals with subacute pain after whiplash injury, Clin. J. Pain source

      Not checked in the free run.

    • cites [62] Ostelo, 2008, Interpreting change scores for pain and functional status in low back pain, Spine (Phila. Pa. 1976). source

      Not checked in the free run.

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

    Study design and conductcitation

    The list of adverse symptoms included the most frequent side effects of treatments for pain.

    “The list of adverse symptoms included the most frequent side effects of treatments for pain [52,57,58].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [52] Attal, 2010, EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision, Eur. J. Neurol. source

      Not checked in the free run.

    • cites [57] Trescot, 2008, Effectiveness of opioids in the treatment of chronic non-cancer pain, Pain Physician source

      Not checked in the free run.

    • cites [58] Varrassi, 2010, Pharmacological treatment of chronic pain—The need for CHANGE, Curr. Med. Res. Opin. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    The app was only available for Android at the time of the study for economic reasons, and Android was the operating system used by more than 90% of phones in Spain.

    “In relation to the limitation to Android operating systems, note that by the time the study was conducted the app was only available for Android for economic reasons, as this is the operating system used by more than 90% of phones in Spain [48].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [48] (2020, September 08). Ericsson Mobility Report. Available online: https://www.ericsson.com/en/mobility-report/reports.

      Not checked in the free run.

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

    Study design and conductcitation

    Interim analyses were not conducted because no harm was expected from adding the app to treatment as usual.

    “As planned, interim analyses were not conducted because no harm was expected from adding the app to TAU [18].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [18] Mesas, 2018, Improving pain treatment with a smartphone app: Study protocol for a randomized controlled trial, Trials source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    The study was as naturalistic as possible and the sample representative of patients treated at the clinic because there were no exclusion criteria in terms of previous or existing treatment for pain at study onset or treatment changes during the study.

    “There were no exclusion criterion in terms of previous or existing treatment for pain at study onset or treatment changes during the study, so that the study was as naturalistic as possible, and the sample representative of patients treated at the clinic.”
    Quote in the paperNot a substantial claim

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

    Study design and conductcitation

    Originally, the planned repeated measures MANOVA was changed to nonparametric statistics because the measures used were ordinal (11-point numerical rating scales).

    “Originally, we planned to explore between and within changes in all study outcomes using a repeated measures MANOVA. However, during the review process it was noted that nonparametric statistics should be used due to the ordinal nature of the measures used (11-point numerical rating scales) [60].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [60] Kersten, P., White, P.J., and Tennant, A. (2014). Is the pain visual analogue scale linear and responsive to change? An exploration using rasch analysis. PLoS ONE, 9. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The study duration was set to one month because the clinicians considered this a critical period in which most problems with the treatment occur.

    “The duration of the study was set to one month since treatment onset because the clinicians considered that this is a critical period in which most problems with the treatment occur (e.g., poor effect on outcomes or side effects).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Data were obtained from 44 patients in the TAU condition, 45 in the TAU + app condition, and 43 in the TAU + app + alarm condition, corresponding to 78.6%, 80.4%, and 81.1% of the initial sample, respectively.

    “Finally, data were obtained from 44 patients in the TAU condition, 45 patients in the TAU + app condition and 43 patients in the TAU + app + alarm condition, which corresponds to 78.6%, 80.4% and 81.1% of the initial sample, respectively.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Change scores have ranged from 30% to 60% across investigations depending on the outcomes and measures used, so the generalizability of findings should be taken with caution.

    “However, change scores have ranged from 30% to 60% across investigations depending on the outcomes and the measures used [61], so the generalizability of our findings should be taken with caution.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [61] Scott, 2014, Clinically meaningful scores on pain catastrophizing before and after multidisciplinary rehabilitation: A prospective study of individuals with subacute pain after whiplash injury, Clin. J. Pain source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.

    “The use of apps may have some benefits in individual health care, especially when using alarms to tailor treatments.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Differences in outcomes across monitoring conditions are due to the assigned monitoring condition.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    Conclusions about the actual sustainability and cost-effectiveness of this new approach to monitoring at a large scale should be taken with caution.

    “conclusions about the actual sustainability and cost-effectiveness of this new approach to monitoring at a large scale should be taken with caution.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Clinician acceptance is critical for implementation purposes.

    “which is critical for implementation purposes [69].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [69] Peters, D.H., Tran, N.T., and Adam, T. (2013). Implementation research in health: A practical guide. Alliance for Health Policy and Systems Research, World Health Organization.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Premisecitation

    eHealth and particularly mHealth will inevitably change health systems in general and pain management in particular.

    “For several years, it has been argued that eHealth and particularly mHealth will inevitably change our health systems in general [63] and pain management in particular [45].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [63] Borrelli, 2015, Special issue on ehealth and mhealth: Challenges and future directions for assessment, treatment, and dissemination, Health Psychol. source

      Not checked in the free run.

    • cites [45] Sundararaman, 2017, Integration of Mobile Health Technology in the Treatment of Chronic Pain, Reg. Anesth. Pain Med. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Patients may experience unusual symptoms for reasons other than the onset of a new pain treatment, such as infection, hormonal changes or a stressful daily event.

    “it is also possible for patients to experience unusual symptoms for reasons other than the onset of a new pain treatment (e.g., an infection, hormonal changes or a stressful daily event, to name some examples).”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    There is no guarantee that the physical symptoms reported by patients are actually due to the recently proposed pain treatment.

    “there is no guarantee that these physical symptoms are actually due to the recently proposed pain treatment.”
    Quote in the paperSubstantial claim

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

    Study design and conductreasoning

    It is difficult to know to what extent technical ability impacted study completion and the final sample size.

    “it is difficult to know to what extent technical ability impacted on study completion and, ultimately, on the final sample size.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    A technical team will probably be needed to address technical problems if technological solutions are to be implemented in routine care.

    “a technical team will probably be needed to address such technical problems if technological solutions are to be implemented in routine care.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [75] Lubans, 2014, Development and implementation of a smartphone application to promote physical activity and reduce screen-time in adolescent boys, Front. Public Health source

      Not checked in the free run.

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

    Premisecitation

    Ecological momentary assessment with the app is feasible in terms of patient response rates.

    “these alarms could be generated because of the ecological momentary assessment with the app, which current and past research has revealed to be feasible in terms of patient response rates [42].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

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

    Interpretationreasoning

    More restrictive benchmarks would possibly have resulted in different percentages of change across conditions and therefore different conclusions.

    “It is possible that more restrictive benchmarks would have resulted in different percentages of change across conditions and, therefore, to different conclusions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    This information has never before been collected with this level of accuracy, using daily assessment as opposed to traditional retrospective assessment.

    “This information has never before been collected with this level accuracy (i.e., daily assessment as opposed to the traditional retrospective assessment).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: This is the first randomized controlled trial exploring the utility of telemonitoring adults with chronic pain between onsite appointments using a smartphone app, and the first study to use an alarm-based telemonitoring system in a randomized controlled trial in chronic pain settings.

  • May combine two claims.

    Study design and conductreasoning

    The focus on musculoskeletal pain only prevents generalizing the findings to specific populations or to all chronic pain populations.

    “the focus on musculoskeletal pain only, which prevents us from generalizing the findings to specific populations or to all chronic pain populations.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning

    Because no analysis of costs was made, it is difficult to know to what extent the implementation of mHealth was cost-effective.

    “because no analysis of costs was made, it is difficult to know to what extent the implementation of mHealth was cost-effective.”
    Quote in the paperNot a substantial claim

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

    Interpretationreasoning

    Inclusion of wearable devices in routine practice may be less ecological than the use of smartphones because smartphones are much more frequently utilized by the population.

    “their inclusion in routine practice may be less ecological than the use of smartphones since the latter are much more frequently utilized by the population.”
    Quote in the paperNot a substantial claim

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

    Premisecitation

    Use of midpoint responses negatively impacts score reliability.

    “the use of midpoint responses negatively impacts score reliability [79].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Weems, 2001, The impact of midpoint responses and reverse coding on survey data, Meas. Eval. Couns. Dev. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The study had limitations including loss of sample due to technical or phone-related problems and reduced power in the analyses.

    “Some study limitations, including loss of sample due to technical or phone-related problems or the reduced power in the analyses have been already discussed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationown data

    Inclusion of an alarm that sends a notification when patient responses are missing for a number of days may be a good strategy to minimize technical problems.

    “the inclusion of an alarm that sends a notification when patient responses are missing for a number of days (e.g., two in the present study) may be a good strategy to minimize technical problems.”
    Quote in the paperNot a substantial claim

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

    Study design and conductreasoning

    The inclusion of a midpoint response in the healthcare professionals' questionnaire may have been problematic.

    “The inclusion of a midpoint response, as in the “Neither agree nor disagree” option in the healthcare professionals’ questionnaire, may have also been problematic.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Ecological momentary assessment could help obtain a more accurate picture of treatment response, which may help guide interventions more effectively.

    “ecological momentary assessment could help us obtain a more accurate picture of treatment response which may help guide interventions in a more effective manner [42].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [42] Castilla, 2018, Validity, reliability, feasibility, and usefulness of Pain Monitor. A multidimensional smartphone app for daily monitoring of adults with heterogeneous chronic pain, Clin. J. Pain source

      Not checked in the free run.

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

    Study design and conductreasoning

    The selection of a 30% cutoff to determine the benchmark for a clinically significant change may have influenced the results.

    “the selection of a 30% cutoff to determine the benchmark for a clinically significant change may also have influenced the results.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    The difficulty of phone follow-up supports the need for more flexible and patient-dependent assessment tools, such as smartphone apps.

    “This supports the need for more flexible and patient-dependent assessment tools, such as smartphone apps.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    If effective, telemonitoring is more likely to have an impact on outcomes if an alarm system allows rapid response to unwanted events, suggesting that daily assessment only is not likely to be sufficient to have an impact on outcomes.

    “it showed that, if effective, telemonitoring is more likely to have an impact on outcomes if an alarm system that allows for a rapid response to unwanted events occurs, which suggests that daily assessment only is not likely to be sufficient to have an impact on outcomes.”
    Quote in the paperSubstantial claim

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

    Premisecitation

    Midpoint responses may be used when participants have no opinion or when they want to provide a socially desirable response.

    “they may also be used when participants have no opinion or when they want to provide a response that is socially desirable [78].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [78] Nadler, 2015, Stuck in the middle: The use and interpretation of mid-points in items on questionnaires, J. Gen. Psychol. source

      Not checked in the free run.

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

    Study design and conductnone given

    The required sample size was obtained based on an uncorrected alpha level of 0.05.

    “the required sample size was obtained based on an uncorrected alpha level of 0.05.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationcitation

    Creating a plan to maintain the app after initial development may help reduce technical problems associated with operating system updates.

    “another option to minimize missing data are to create a plan to maintain the app after the initial development is completed, which may help reduce technical problems associated with operating system updates [76].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [76] Price, 2014, mHealth: A mechanism to deliver more accessible, more effective mental health care, Clin. Psychol. Psychother. source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Technical problems such as app malfunctioning or phone problems occurred in the study and resulted in almost 20% loss in sample size.

    “such as app malfunctioning or problems with the patients’ phone, such as crashing or low battery or memory, these did occur in the study and resulted in almost 20% of loss in sample size.”
    Quote in the paperNot a substantial claim
74 of 74

  • The paper relies on this without support.

    Pain treatment follow-up is predominantly discrete during on-site appointments.

    “For example, pain treatment follow-up is still predominantly discrete during on-site appointments.”

  • The authors state this as an assumption.

    Differences in outcomes across monitoring conditions are due to the assigned monitoring condition.

    “All patients received the usual treatment for their pain, so differences in outcomes (pain severity and interference, fatigue and mood) across outcomes were expected to occur as a consequence of the assigned monitoring condition.”

  • The authors state this as an assumption.

    Daily response to pain-related items in the app does not by itself produce patient benefits; any benefit of the app + alarm condition is due to telemonitoring.

    “Because we want to ensure that telemonitoring and not the daily response to pain-related items in the app is responsible for patient benefits, we allocated patients using the app into two conditions: telemonitoring (i.e., use of the app with alarms to the physician in the presence of unwanted events detected by the app) and daily app use without alarms.”

  • The paper relies on this without support.

    This is the first randomized controlled trial exploring the utility of telemonitoring adults with chronic pain between onsite appointments using a smartphone app, and the first study to use an alarm-based telemonitoring system in a randomized controlled trial in chronic pain settings.

    “to the best of our knowledge, this is the first randomized controlled trial that explored the utility of telemonitoring adults with chronic pain between onsite appointments using a smartphone app.”
    “To the best of our knowledge, this is the first study to use an alarm-based telemonitoring system in a randomized controlled trial in chronic pain settings.”
4 of 4

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?

  • Suso-Ribera et al.'s results were suggestive of the effectiveness of telemonitoring in pain and other mental health outcomes (e.g., depressive symptoms), particularly if an alarm system that allows changes in pain management can be implemented.

    “the results of this study were suggestive of the effectiveness of telemonitoring in pain and other mental health outcomes (e.g., depressive symptoms), particularly if an alarm system that allow changes in pain management can be implemented.”

    From Using Information and Communication Technologies (ICT) for Mental Health Prevention and Treatment (2021) · cites this paper as [11]

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentz = -3.32reported p < .001 · recomputed p < .001

    “(Z = −3.32, p < .001”

1 of 1

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.

  • Alarm-handling time is described as both a daily total and a per-alarm cost

    Minor

    The reported 28 minutes is the time physicians spent responding to all daily alarms, but the discussion treats approximately 30 minutes as the time required for each alarm. Those are different denominators for the same workload estimate.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 4

  1. Kaiser, 2017, Developing a core outcome-domain set to assessing effectiveness of interdisciplinary multimodal pain therapy, Pain, 1, 673
  2. 2018, Influence of psychosocial factors on the experience of musculoskeletal pain: A literature review, Rev. Soc. Española Dolor, 26, 44
  3. McCracken, 2016, A reduction in pain intensity is more strongly associated with improved physical functioning in frustration tolerant individuals, J. Clin. Psychol. Med. Settings, 23, 192
  4. Holm, 1979, A simple sequential rejective method procedure, Scand. J. Stat., 6, 65

Cited by

Sorted by citations

Related

Authors
Suso-Ribera, C., Castilla, D., Zaragozá, I., Mesas, Á., Server, A., Medel, J., & García-Palacios, A.
Affiliations
  • Department of Basic and Clinical Psychology and Psychobiology, Universitat Jaume I, 12071 Castellón, Spain
  • Universitat de València (ES)
  • Instituto de Salud Carlos III (ES)
  • Pain Clinic, Vall d’Hebron Hospital, 08035 Barcelona, Spain
  • Vall d'Hebron Hospital Universitari (ES)
ORCID
Venue
International Journal of Environmental Research and Public Health
Publisher
MDPI AG
Published
2020-09-09
Volume
17
Issue
18
Pages
6568
ISSN
1660-4601 (ISSN-L)
DOI
10.3390/ijerph17186568
PMC
PMC7559749
OpenAlex
W3084131226
Semantic Scholar
bd5d6e57fb4c45784ce9770204a34afcbfd21e2a
Cited by
38
References
77
Citations by year
2026: 4 · 2025: 6 · 2024: 11 · 2023: 5 · 2022: 4 · 2021: 8
FWCI
4.43
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Environmental Research and Public Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Repositori UJI (Universitat Jaume I) (acceptedVersion, cc-by-sa)
  • RePEc: Research Papers in Economics (submittedVersion)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, cc-by-sa)
  • LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) (submittedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
  • Repository of Digital Objects for Teaching Research and Culture (University of Valencia) (submittedVersion, other-oa)
Funders
  • Universitat Jaume I (POSDOC/2016/15)
  • Valencian Community Government (GV_2019_095)
Topics
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
Keywords
remote patient monitoring, chronic pain, musculoskeletal pain, mobile application, mobile health, clinical alarm systems, pain intensity, pain interference, fatigue, depression, anxiety, anger, clinician acceptance, personalized treatment
MeSH terms
Smartphone, Humans, Clinical Alarms, Chronic Pain, Pain Management, Mobile Applications

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 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

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.

What counts as a claim ›How we measure confidence ›How we check this ›

Are you an author, or do you see a problem with this page? Request a review