JMIR Publications

ABSTRACT

Background:

Low back pain (LBP) is the number one leading cause for worldwide years lost due to disability with a tremendous economic burden for healthcare systems. Digital therapeutic care (DTC) programs provide a scalable, universally accessible, and low-cost approach for the multidisciplinary treatment of LBP. Moreover, novel decision support interventions, such as personalized feedback messages, push notifications, or data-driven activity recommendations, amplify DTC by guiding the user through the program while aiming to increase overall engagement and sustainable behavioral change.

Objective:

This systematic review aims to synthesize recent scientific literature on the impact of digital therapeutic care applications (apps) for people with LBP and outline the implementation of add-on decision support interventions, including their effect on user retention and attrition rates.

Methods:

We searched bibliographic databases including Medline, Cochrane Library, Web of Science, and PEDro from March 2016, until 2020, in accordance with the PRISMA guidelines, and conducted this review based on related prior published systematic reviews. Besides randomized controlled trials, we also included study designs with the evidence level of at least a retrospective comparative study. This enables the consideration of real-world user-generated data and provides information regarding the adoption and effectiveness of DTC apps in a real-life setting. For the appraisal of the risk of bias, we used the RoB2-tool and the ROBIN-I tool for the randomized and non-randomized trials, respectively. Included studies were narratively synthesized regarding primary and secondary outcome measures, DTC components, applied decision support interventions, user retention, and attrition rates.

Results:

We retrieved 1,388 citations, of which twelve studies are included in this review, involving six RCTs and six non-randomized trials. In all twelve studies, the DTC intervention group resulted in lower pain levels and increased functionality compared to baseline values. In-between group comparison revealed significant improvements in pain and functionality levels in four out of six RCTs. The study population was mostly homogenous with predominantly female, normal to moderate weighted, and young to middle-aged participants. The methodological quality assessment revealed moderate to high risks of biases, especially in the non-randomized trials.

Conclusions:

This systematic review demonstrates the benefits of DTC for people with LBP. There is also evidence that decision support interventions benefit overall engagement with the app and increase participants' ability to self-manage their recovery process. However, due to mostly homogenous study populations and the unclear correlation between user retention and improvements in primary outcomes, no general conclusion can be made on the right intervention duration nor the required number of exercise modules for individual cohorts. Finally, including retrospective evaluation studies of real-world user-generated data into future systematic reviews of digital health interventions trials can reveal new insights into the benefits, challenges, and real-life adoption of digital therapeutic care programs.