記住我
Musculoskeletal conditions, those affecting the bones, muscles, and joints, are recognized as a global public health problem, although the prevalence and burden of healthy life lost are difficult to estimate with certainty because population studies are few []. Where representative studies have been conducted, they have consistently shown high prevalence of musculoskeletal conditions that increases with age and has a greater burden on female than male individuals [-]. In the Health Survey for England 2018, a total of 17% of adults reported having a long-term musculoskeletal condition (19.5% female vs 14.2% male), with prevalence increasing with age (4.7% at the ages of 16-24 years vs 39% at the age of ≥85 years). A total of 80% of people who reported having a long-term musculoskeletal condition also reported chronic pain (pain for >3 months), with 34.8% reporting pain that highly interfered with their life activities [,]. The Australian National Health Survey 2017 to 2018 reported that 29% of Australians were living with a chronic musculoskeletal condition (age standardized; adults aged ≥45 years: 51%; 55.3% female vs 47.3% male) []. musculoskeletal conditions were the second leading contributor to total burden of healthy life lost, equal to the burden of cardiovascular disease (13% of total burden in disability-adjusted life years), second only to cancer (18% of total burden) []. Prioritizing the delivery of effective treatments is necessary to address the substantial burden of musculoskeletal conditions.
With the ubiquity of consumer devices such as smartphones and tablets, technology may have a useful role to play in the management and self-management of musculoskeletal conditions; potentially improve accessibility of health care; and, in some circumstances, ease health system pressures. The use of technology for providing health-related activities is typically described as “digital health” and, more specifically, “mobile health” (mHealth) when referring to the use of mobile devices. While still a relatively new field, mHealth already has a considerable literature base, with examples of its use across most health disciplines and across the continuum of care from health promotion and prevention [,] to screening and diagnosis [,], therapy [,], and self-management [,] to cancer survivorship and palliative care [,]. While mHealth shows promise in improving aspects of health care, evidence to date is mixed, and caution is needed in interpreting the clinical value of mHealth for patients [].
In this review, we focused on the development and use of mHealth for individuals with musculoskeletal pain conditions and specifically on health-related interactions that use text messaging as the delivery mechanism (SMS text messaging or messages provided via app-based push notifications), either alone or alongside another intervention. As one of the mobile technologies that have been established for longer, text messaging is familiar, easy to use, convenient, low cost, and available to anyone with a mobile device []. Messaging can be used as a vehicle to promote behavior change and guide self-management through prompts, reinforcement, reminders, activity recording, feedback, and adaptivity to the individual [,]. The effectiveness of messaging interventions has been assessed for a wide range of health problems, such as medication adherence and lifestyle change in diabetes; encouraging abstinence in smoking cessation; and, more recently, to encourage prevention behaviors during the COVID-19 pandemic [,-].
In total, 2 previous reviews have explored the effectiveness of text messaging–based interventions for musculoskeletal conditions [,]. In a broad review of 19 randomized controlled trials (RCTs; 1086 participants) [], 5 studies involved aspects of messaging [-], with 4 studies reporting improvements in pain [-] and functional disability [-] favoring digital interventions but not specifically favoring the messaging components []. A second review focused specifically on the effectiveness of text messaging–delivered interventions included 11 RCTs (1607 participants) []. Of the included studies, 5 assessed text messaging as an adjunct to usual care on treatment adherence and found improvements favoring text messaging [-]. In a further 5 RCTs, the effectiveness of text messaging as 1 component of a complex intervention was assessed [-], finding small but inconsistent effects on pain, functioning, adherence, and quality of life. In 1 RCT, text messaging was compared to telephone counseling, and similar effects on functioning were reported [].
ObjectivesThese previous reviews focused on intervention effectiveness and synthesized data from RCTs only. The findings of observational studies have not been synthesized, and these studies may contain useful information to inform and, ultimately, improve the effectiveness and adoption of future musculoskeletal interventions delivered using text messaging. Furthermore, important characteristics of interventions, such as the configuration of digital content, method of presentation, dose, frequency, and preferences, have not been synthesized. Consequently, to inform the design, development, and evaluation of future messaging interventions for people with musculoskeletal pain, we need to explore the literature using a wider lens. Therefore, in this study focused on individuals with musculoskeletal pain conditions, we had three aims: (1) to map the literature related to the use of mobile messaging; (2) to identify information that could be useful in the design of future messaging interventions; and (3) to explore and summarize the findings on efficacy, effectiveness, and economics derived from previous experimental and observational messaging studies.
We designed and conducted this review according to a preregistered and published protocol [] developed using the Joanna Briggs Institute Manual for Evidence Synthesis [] and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) [] guidelines. The methods are described in full in the published protocol and summarized in brief in the following sections.
Review QuestionsResearch question (RQ) 1 was as follows: In the context of musculoskeletal pain conditions, for which individuals, with which problems, and for what purpose, has messaging on mobile devices been used (eg, medication reminders, alerts, education, motivation, prevention, and data collection)?
RQ 2 was as follows: What information exists to guide the development of mobile messaging for musculoskeletal pain conditions (eg, frequency of messages, length of messages, duration of the intervention, and theoretical basis)?
RQ 3 was as follows: How have patients’ preferences been included in the design of a study, and how have their preferences been assessed?
RQ 4 was as follows: What methods have been used to evaluate the use of mobile messaging for musculoskeletal pain conditions (eg, how were outcomes assessed and what processes were involved)?
RQ 5 was as follows: Does the literature support the efficacy, effectiveness, and economics of messaging on mobile devices for individuals with musculoskeletal pain conditions?
Inclusion CriteriaParticipantsWe included studies on adult participants with acute or chronic musculoskeletal pain conditions.
ConceptThe concepts of interest were the development or evaluation of patient-focused health-related messaging (eg, SMS text messaging and app push notifications) provided on mobile devices such as smartphones and tablets.
ContextWe included articles that described messaging used in any setting either as a primary intervention or as an adjunct to other interventions. We excluded studies focused on spinal cord injury, traumatic brain injury, moderate to severe orthopedic injuries, surgical patients, and conditions related to mobile phone overuse. We also excluded studies focused on health conditions primarily unrelated to the bones, muscles, and connective tissue (eg, diabetes, asthma, cancer, and stroke).
Data SourcesWe searched PubMed, CINAHL (via EBSCOhost), Embase, and PsycINFO (via APA PsycNET) using a strategy that combined controlled-vocabulary and free-text search terms related to messaging and musculoskeletal concepts. Because of resource limitations, we were unable to include gray literature in our searches.
Search StrategyThe search strategy is described in detail in the published protocol [], and the search queries are provided again in this paper in . The search strategy was developed through discussion among the team and an iterative process of pilot searches. The final searches were conducted by SSR. Because of resource limitations, we restricted our searches to articles published in English, and because the area of digital health is a rapidly changing field, we limited our searches to articles published in the previous 10 years.
Study SelectionWe exported search results to EndNote (version X9; Clarivate Analytics) and Covidence (Veritas Health Innovation) [] for duplicate removal and to manage the screening, selection, and record-keeping processes. We conducted study selection in 3 phases. First, using the predefined inclusion and exclusion criteria, 2 independent reviewers (from a pool of 7; SSR, JL, CEE, RE, CR, SR, and NA) screened the titles and abstracts to identify candidate articles for inclusion and to discard irrelevant articles. Second, 2 reviewers from the same pool reviewed the full text of each candidate article. Third, we searched the reference lists of the included papers to identify any further articles. At all stages, conflicts were resolved using a third reviewer from our pool.
Data ExtractionData were extracted by one reviewer (JL) and independently confirmed by 2 others (NA and CEE). Data were extracted using predefined extraction forms, as described in the protocol [].
Synthesis and ReportingWe described the results of the study selection process using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram [], with findings reported in accordance with the PRISMA-ScR checklist []. For each of our 5 review questions, we structured our findings using tables adapted from the Joanna Briggs Institute manual [] refined as necessary at synthesis stage []. We then developed a narrative summary of the evidence for each of our review questions.
Protocol DeviationsThere were 4 minor protocol deviations. First, we excluded studies that described the use of mobile messaging to collect data in cases in which those data were not subsequently used to inform care or self-management (eg, studies that simply tested the feasibility of using text messaging to collect data and studies that used text messaging as a data collection method to model recovery trajectories). Second, we included study protocols associated with evaluation studies if they provided useful information about messaging design and development. Third, we classified the level of development of the country in which the study was conducted using the Human Development Index (HDI) []. Finally, we reran our searches in 2022 and, therefore, included studies from a 12-year period rather than the originally specified 10 years.
Literature searches were conducted in August 2020 and repeated in May 2022. In this section, we present the combined results of both searches. We identified a total of 8328 papers (published in 2010-2022) for screening, of which 50 (0.6%) were included in this review. A PRISMA flowchart of the article selection process is shown in .
Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart—article selection process. *No registers were searched; **No automation tools were used; MSK: musculoskeletal. We identified 3 previous systematic reviews, 2 (67%) of which we had already found while developing the protocol for this review [,] and 1 (33%) that was new []. One review focused specifically on the effects of text messaging for managing musculoskeletal pain conditions [], while the remainder focused more broadly on digital health or mHealth for musculoskeletal conditions but covering some aspects of messaging [,]. The previous reviews were conducted in Australia, the United Kingdom, and the Netherlands, all countries classed as very highly developed according to their HDI. The characteristics of the reviews are shown in , and the findings are shown in . We did not identify any previous reviews related to design aspects of messaging for musculoskeletal pain conditions.
We included 47 papers describing 40 primary studies (22/40, 55% experimental; 16/40, 40% observational; and 2/40, 5% mixed methods). In total, 10% (4/40) of the experimental and observational studies had associated or embedded qualitative or mixed methods studies. The results of 5% (2/40) of the studies were multiply reported, and 8% (3/40) of the studies had either an associated design paper or a protocol paper containing design information. A total of 18 countries were represented, with the United States publishing the largest number of studies (9/40, 23%) followed by Australia (6/40, 15%) and Denmark (4/40, 10%). By HDI, most primary studies were conducted in very highly developed countries (36/40, 90%), 8% (3/40) were conducted in highly developed countries, and 3% (1/40) were conducted in a country of medium development. No studies were reported from countries of low development.
At the time of our search, 70% (35/50) of the previous reviews and primary studies had been published in the 3 years before our search. The characteristics of the primary studies are shown in and [,,,-,-,-].
Table 1. Characteristics of review papers related to messaging for people with musculoskeletal (MSK) pain conditions.Study, year; typeCountrya (HDIb)Review focusStudies and sample sizeMSK condition focusPrimary outcomesMessaging methodAdjunctaOn the basis of the lead author’s affiliation.
bHDI: Human Development Index [].
cSR: systematic review.
dVH: very high.
eRCT: randomized controlled trial.
fReview included surgical studies; we report the subgroup of nonsurgical studies or participants in this table.
gQoL: quality of life.
hScR: scoping review.
imHealth: mobile health.
jRA: rheumatoid arthritis.
Table 2. Findings of review papers related to messaging for people with musculoskeletal (MSK) pain conditions.Study, yearIndividuals, problems, and purposeDesign-related informationOutcomes assessed and review findingsFritsch et al [], 2020—effects of text messaging for managing MSK painReview included 7 RCTsa on patients with MSK pain conditions (3 with RAb, 1 with chronic widespread pain, 1 with upper- or lower-limb MSK injuries, 1 with frozen shoulder, and 1 with knee pain) [-,-,]aRCT: randomized controlled trial.
bRA: rheumatoid arthritis.
cQoL: quality of life.
dUC: usual care.
eSF-36: 36-item Short-Form Health Survey.
fMCS: Mental Component Summary.
gPCS: Physical Component Summary.
hAE: adverse event.
imHealth: mobile health.
j19-item Compliance Questionnaire on Rheumatology, incorrectly described as the 9-item Compliance Questionnaire on Rheumatology in the review by Seppen et al [].
Table 3. Characteristics of primary studies related to messaging for people with musculoskeletal (MSK) pain conditions.Study, yearCountrya (HDIb)DesignPrimary aimMessaging methodAdjunctaOn the basis of the lead author’s affiliation.
bHDI: Human Development Index [].
cVH: very high.
dMobile health design paper.
eH: high.
fMessaging-specific design paper.
gMessaging provided using a social media app.
hM: medium.
Figure 2. Overview of 47 papers describing 40 primary studies by condition, purpose, and role of messaging. The circled numbers represent the number of papers. CBT: cognitive behavioral therapy; MSK: musculoskeletal; PA: physical activity; PROM: patient-reported outcome measure. RQ 1: Individuals, Problems, and PurposePrevious ReviewsIn the previous reviews [,,] ( and ), the most commonly reported messaging interventions were for people with rheumatoid arthritis (RA) and back pain. For RA, messaging was used to monitor medication and disease activity [] and improve medication adherence [,] and for reminders to reduce daily sitting time [,]. For people with back pain, messaging was used mostly as a component of self-management, with approaches focused on education and behavior change strategies [,], supportive messages provided by a health coach during periods of low engagement with a digital self-management program [], and motivating messages sent as part of a multidisciplinary pain program [].
Other studies described uses of messaging for people with knee pain, systemic lupus erythematosus, frozen shoulder, chronic widespread pain, and limb injuries or conditions. For knee pain, one study reported a lifestyle intervention focused on behavior change [,], and another reported participation reminders and app-based messaging with a personal coach as part of an exercise, education, or cognitive behavioral therapy (CBT) or weight loss or psychosocial support program [,]. For frozen shoulder, reminder, encouragement, and education messages were used to promote exercise compliance and improve shoulder function []. For chronic widespread pain, a CBT intervention used SMS text message diary completion prompts, with those diary entries then informing the treatment used by a therapist []. For limb injuries and conditions, messaging was used to promote adherence to a home exercise program in one study [].
Primary StudiesRheumatic diseases accounted for the largest proportion of the included primary studies (19/40, 48%), followed by studies on multiple musculoskeletal conditions or pain sites (10/40, 25%), back pain (9/40, 23%), neck pain (1/40, 3%), and “other” (1/40, 3%; ).
Rheumatic DiseasesOf the 19 rheumatic disease–related studies, 8 (42%) focused on osteoarthritis [,,,,,-,-], 5 (26%) focused on RA [,,,,,,], 2 (11%) focused on fibromyalgia [,,], 2 (11%) focused on osteoporosis [,], and 1 (5%) each focused on ankylosing spondylitis [] and chronic arthritis [].
Of these 19 studies, 14 (74%) described the use of messaging to promote behavior change with the intention of improving levels of physical activity, assisting weight loss, improving sleep, or reducing stress [,,,,, ,,,,-,,-]. A total of 11% (2/19) of the studies described messaging for providing information [,], and 5% (1/19) described the use of messaging to collect data for disease monitoring and guide clinical care []. In total, 26% (5/19) of the studies described aspects of design and development of messaging systems for people with knee osteoarthritis [,], osteoporosis [], and chronic arthritis []. The design and development aspects are described in later sections.
Osteoarthritis StudiesOf the 8 studies on osteoarthritis, 2 (25%) focused on behavior change based on personalized goals. In the first study, which proposed personalized goals based on machine learning, participants were sent daily push notifications to remind them of their goals together with an interesting fact or answer to a frequently asked question [,]. Similarly, the second study used messaging to provide reminders to complete individualized physician-assigned goals and tasks, for which participants also used messaging to provide confirmation, or otherwise, that they had completed their personalized goals [].
A total of 4 (50%) of studies focused on physical activity and exercise behavior change for people with knee osteoarthritis: of those, 1 (25%) used messages to decrease inactive behavior in people with knee osteoarthritis [] and another (25%) used targeted personalized motivational reinforcement messages based on previous and current physical activity for people with osteoarthritis and sleep disturbance []. In the third study, which had an experimental design, the authors also explored patient attitudes and experiences of a self-directed digital health intervention incorporating automated messages to support strengthening exercises [,]. The fourth study, in which 77% of participants had knee osteoarthritis, described a digital care program that sent participants reminder messages if they did not engage with the program at the required intensity and also allowed participants to communicate with their health coach using messaging [].
A single study focused on providing information for people with knee osteoarthritis, where messages were used to improve patients’ knowledge about their condition and treatment options before consultation with their specialist as part of shared decision-making [].
A further study focused on knee osteoarthritis prevention, describing a self-management lifestyle intervention for young to middle-aged rural-dwelling women that incorporated messaging to provide key behavior reminders [].
RA StudiesOf the 5 studies on RA, 2 (40%) used message reminders as part of a motivational counseling intervention to reduce sitting time [,,], and 1 (20%) focused on physical activity behavior change with messaging used for coaching, prompts, reminders, and monitoring of physical activity program adherence [,]. A further study assessed the effects of text messages on medication adherence []. One study collected data using text or app-based messaging for symptom or disease monitoring and patient-reported outcome measures [].
In a study that recruited women with chronic widespread pain (80% met the American College of Rheumatology criteria for fibromyalgia), text messaging was used to prompt diary completion and allow participants to exchange short messages with their therapist. The diary information was used by therapists to inform patient care [,]. A second guided imagery study also focused on people with fibromyalgia used text messaging to remind participants to practice their imaging exercises together with randomly selected reinforcement messages [].
A study on patients with osteoporosis and nontraumatic fractures used text messaging to provide patients with treatment advice based on a validated fracture assessment tool and assessed whether the advice provided subsequently changed primary care physician management of their fracture [].
Finally, one study described the use of social media messaging (WeChat) for people with ankylosing spondylitis, with messaging used for appointment reminders, for communication between physicians and patients, to record follow-up information, and for patients to provide feedback [].
Multiple Musculoskeletal Conditions or Pain SitesA total of 10 studies focused on multiple musculoskeletal conditions or pain sites (n=1, 10% each on the neck or back [], neck, shoulder, or back [], and chronic knee or low back pain [LBP] []). A total of 50% (5/10) of the studies recruited participants with a range of musculoskeletal problems typically seen in the general population [,,,], and 20% (2/10) of the studies recruited adults with chronic pain but not pain exclusively of musculoskeletal origin [,]. A further study focused on chronic musculoskeletal pain in veterans [].
Of these 10 studies, 9 (90%) described behavior change interventions [,-,-,], and 1 (10%) was focused on providing information [].
For neck and back pain, one study described the use of an artificial intelligence–enabled app that implemented evidence-based guidelines for self-management, with messaging provided within the app to remind participants to exercise and provide contact with the treating team []. A second study on workers with neck, shoulder, or back pain also described the use of artificial intelligence, wherein a chatbot provided messages with exercise instructions and suggestions for symptom improvement []. One study focused on chronic knee or LBP described a digital care program incorporating sensors and an app that allowed participants to communicate with a personal coach via SMS text messaging and app-based messaging [].
Another 20% (2/10) of the studies included adults with chronic pain but not exclusively pain of musculoskeletal origin [,]. The first included patients being treated by a hospital-based pain management service for a range of conditions (LBP; cervical or upper-extremity, lower-extremity, abdominal or pelvic, and head or face pain; and multiple pain sites, with pain of ≥4 on a 0-10 scale). Participants used an app that incorporated reminders to complete daily assessments and also provided 2-way messaging []. The second study, with similar wide-ranging pain sites, used automated text messaging to prompt skill practice as part of an internet-delivered CBT program for chronic pain [].
Regarding patients attending hospital physiotherapy services for a range of musculoskeletal problems, 10% (1/10) of the studies examined whether SMS text messaging could increase home exercise compliance []. In this study, compliance with exercises was encouraged via motivational SMS text messages sent by the physiotherapist. Similarly, the use of messaging to encourage home exercise compliance was described in a study on patients with musculoskeletal problems attending a chiropractic clinic [].
In the physiotherapy outpatient setting, the use of SMS text message reminders to reduce clinic nonattendance was described in 10% (1/10) of the studies [].
A total of 20% (2/10) of the studies focused on specific populations. The first, a community-based study, aimed to improve the physical activity of older adults (aged ≥60 years, most of whom had musculoskeletal problems) and used social media messaging (WhatsApp) to inform participants of scheduled walks and promote social interaction between participants []. The second study focused on a chronic musculoskeletal pain program in veterans and used behavior change messaging for stress management and adoption of healthy sleep practices and to increase engagement and retention in the program [].
Back PainA total of 20% (8/40) of the studies described behavior change interventions [,,-,], and 5% (2/40) described the design and development (described in a later section) [,]. Of the 8 behavior change studies, of these 4 (50%) described the use of individual or personalized messaging for physical activity goal reminders and reinforcement [], encouragement messages and physical activity suggestions [], motivational notifications for self-management [,], and individual activity level–based feedback messages provided on a PDA to encourage behavior change []. A total of 13% (1/8) of the studies described a self-management app with notifications to encourage walk breaks and posture exercises [].
A total of 38% (3/8) of the studies described the use of 1- or 2-way messaging with a health coach, physiotherapist, or sports scientist for support, encouragement, and participation reminders as part of self-management programs [,,].
Neck PainOnly 3% (1/40) of the studies focused specifically on neck pain. This study described a behavior change intervention for office workers with chronic neck pain incorporating weekly messages about caring for their pain with information about the importance of exercise and to provide encouragement to complete prescribed exercises [].
Other ConditionsA total of 3% (1/40) of the studies, on patients with frozen shoulder recruited from an orthopedic outpatient clinic, used messaging to provide reminders, encouragement, and education to promote shoulder exercise compliance [].
RQs 2 and 3: Design and Development and Patient PreferencesOverviewIn this section, we report findings related to the design and development of messaging interventions. Because patient preferences, where accommodated, were generally addressed through participatory or co-design, we have reported the results of review questions 2 and 3 together. The findings are presented in three groups: (1) information found in papers specifically focused on the design and development of messaging interventions, (2) information found in mHealth design papers where some aspect of messaging was described alongside other mHealth functions, and (3) incidental design and development information found in papers that reported the results of messaging or mHealth interventions. The design-specific papers are shown in and [-].
Table 4. Papers focused on messaging design and development and patient preferences.Study, yearRole of messagingDesign process (theory, method, and outcomes)Johnson et al [], 2017—describes the participatory design and pilot study of an mHealtha self-management program for veterans with chronic MSKb painTailored messages were an optional component intended to increase engagement and retention.
留言 (0)